 We are now back on the record. Thank you. I'm going to have to take one more break so I get a chance to do it right. Sorry. Member Walsh, if you have any questions, please go ahead. Thank you. Thank you, chair Foster. And good afternoon, everyone. From one care. I've spent a lot of the break just trying to. Go over some things and really. Change a lot of what I had in mind. Basically because of the strength of your presentation this morning. I thought it was really, really good. And. If you have it available and could bring up like slide. 19 to 22 in particular. I want to highlight what I appreciated so much about it. And I'm going to go over some things. I want to highlight what I appreciated so much about it. And go to slide 19. Right. So in this. 2024 approach where. The alignment that you're talking about and then. The change to the population health. Model program where the base payments are somewhat less. And the ability to earn bonuses or. Incentives has grown. And then. What you also show is that in the next slide. You've. Analyze the data that you have available to show where there are. Strengths and weaknesses across. All your members. And then aligned the incentives to try to. Incentivize improvement in the scores that need it. So you really see that you're using the, the. The data to figure out what you're the members of. The ACO team, the, the, the network need. And then figuring out ways to help them with that. And that's aligning incentives, but developing programs. Providing feedback if we could go. To the next slide. Maybe it's the next where it's a through. Well, maybe there are more that I liked, but there was 1 slide that really showed all of the, all of the 10. Members and their performance that maybe that was a mental health screening initiative. But that's the type of feedback. This is another 1. The type of feedback that. Health care delivery systems can really respond to and try to figure out what they can do better. Could we go 1 more? That's. I think it's under the mental health, but. But what we're able to see. And we see your, we see your budget, but we also see what that money is being used for. It's to analyze the performance of. The organizations that participate with you. That's the 1 that I was just referencing. And then. Providing that information back in a way that is motivating. See, I don't know what 10 I am in this and I fear that I'm going to be W or X. And so I'm going to work really hard to try to get closer to a. And that's just the quality improvement principles. That an ACO can can really bring. And I was just really encouraged. By this presentation this year, it's, it's like, it's a different organization. From last year. And so I really want to applaud that. I also, I want to frame the rest of my questions. I'm going to keep coming back to the things that are applaud that I'd like to applaud. The questions are based on the narrative that was submitted with the budget. And there things weren't so clear. And some of the questions I want to also ask some questions about, about nork. And there things are a little bit muddy too. And I'm not trying to be extra critical. I'm trying to be a good regulator. I've been trying to look at where's the, here's the budget for the organism for your organization. And can we see what it's what that money is accomplishing. So really good things in this presentation, really clear about what you're trying to do, how you're deciding what to do. And it's, these are features of high functioning acos not every aco is high functioning. And the, the, the first nork report that I just wonder if you got, if you're familiar with the one about next generation acos not about Vermont specifically, but about acos in general. That report found that Medicare saved money. At first through aco initiatives. But after they paid out shared savings, they actually lost money. So acos as a whole have failed across the country. They haven't met the goals of saving money for Medicare. And I'm, I'm wondering what. How do you, how do you attribute your success? Where do you attribute your success with Medicare? The Vermont nork report said you saved Medicare money. And how are you different? What are the unique things that you're doing to produce those savings? I can take the first stab at that. I think, thank you firstly for your, your comments. I very much appreciate them. I think we, the really some of the differences between the success of Vermont is, is the whole state. I think that Vermont has a track record of being a leading edge of healthcare improvement and reform efforts that goes back decades. You know, the blueprint is a, is a huge player in it. It's part of our culture as well. This is always trying to be better. And I think he mentioned our New England grit. I think that's part of it as well. And I think that while it's been challenging to get the entire state engaged in these programs, we do have very broad spread participation in this concept across all of Vermont. I think that's huge. I think it's really important to what we've been able to achieve here. I mean, no one entity, particularly one care can solve all these problems. But if we're all working together on these shared goals and all playing our part and trying to figure out our unique roles in the evolution and improvement. I think that all contributes to why we've seen some really good results in Vermont. Things aren't perfect. There's lots, lots more to do. But I think we should be building on that foundation of widespread participation, multiple entities and parties contributing to the, to the endeavor. And trying to just continue to build on what's worked well, tinker in advance, learn from what we've experienced in the past and keep the momentum. I just add to that that, you know, the statewide nature of our ACO and the level at which we foster collaboration across the entire continuum is really different. Member Walsh than other ACOs that have generally a fairly narrow focus of a single tin or single entity and very limited geography. And it's been both an advantage to us as well as, you know, honestly, a challenge in some of the work that we've done to bring together such a huge disparate area. But I appreciate the kind words and you should know that, you know, we took your words to heart last year and we really tried to structure our approach and our presentation and our budget around having real impact. And, you know, come up with measurable ways that we could define success in the coming year. Well, thank you for that. And again, I'm very impressed with with this year's edition. I think there's a lot of truth and that the intangibles about Vermont, you know, being a special place and having a long history in health care reform efforts. So that that leads me to the to the second questions about the Vermont NORC report, right? Savings did not occur in the commercial arm and the Medicaid arm. So why do you think the Medicare savings occurred but Medicaid and commercial did not? Just to be clear, the NORC report is commissioned by CMI to evaluate only the Medicare portion of the all payer model. So, I'm not, I want to make sure I understand your question. You're asking about savings that were generated in Medicaid and commercial programs but not as part of the NORC report just in general. So, thanks for clarifying that it's, I think I'm blending a couple of things with with my questions. The NORC report showed Medicare savings. But Medicaid and commercial savings are not apparent from the other data that we have available. And so I'm wondering what. How do they, how do the programs differ? You know, so they are different structured programs. Tom, I don't know if you'd like to comment. I actually think that we have generated savings on the Medicaid program over time. And again, those are versus whatever the target structure was within that program. So Tom, I don't know if you want to expound on a little bit. Sure. Yeah, we have a number of years of data to look at in the Medicaid program. It's been probably our most consistent program over time and it grew a lot. The first couple of years were the most challenging. We had shared losses in 2018 and 19 and then shared savings earned in 2020, 21 and 22. 2023 current projections are that we're actually very close to target and our data lag a couple of months back for completion reasons. So it can really land on either end of the line, but I think being pretty close to target is still a decent outcome overall. So we've had a lot of success in that Medicaid program earning shared savings. And I said before, I hope that the shared savings is kind of a reinvestment concept that you know, providers that receive these funds can continue to invest in the work that we know or and think will help us continue to manage total cost of care and improve quality over time. Okay, thank you. And thanks for helping me clarify with with the Medicare. Aspect and the savings shown in the NORC report. Can you point to an analytic insight or a program that was developed that that you believe drove or led to those savings? I don't think there's a single thing in my mind that would be like a single analytic that says this was it that got the savings. I I view this as a paradigm shift. We are trying to install and make sure that this concept of awareness of total health care costs is ever present within the that to me is what was missing. Prior to ACO business is everyone was doing good work in their own organizations and shops, but there wasn't a real clear understanding of what total health care experience was for their patients. So through time and this again as part of the collaborative within Vermont, installing this concept where there's a greater awareness of total health care costs and the importance of care coordination collaborating together using data. All of these come together as a strategy to try and lower health care costs over time and I think have contributed to our success. I think before to that I worry about ACO is that really aggressively pursue one change in spirit of cost savings. I'm not sure that sustainable and I'm not sure that's better health care. So we've taken a much more of a bottom up approach of how do we solidify the foundation of health care through primary care? How do we use data to improve? How do we coordinate care? So all that's done well, we should see control of total health care costs. Lots left to do, but I do feel like that paradigm shift is taking hold and is contributing to our overall results. And if I could just add to that, just to paraphrase one of our participants, it's a primary care provider. She said we take for granted now that independent primary care practices sit down at the table with hospitals and other providers in their community conversations about how to reduce total cost of care and provide better quality outcomes. That did not happen a decade ago. So we've come to expect that that happens, but a lot of the work we've done with the board as part of building out the Vermont all pair model has fostered those connections and communications. And as Tom said, the awareness of this so it's hard to point to one specific metric or one specific initiative. But I think through fostering collaboration, facilitating data sharing and evolving the payment model, we've been able to holistically move the needle a little bit, member wash. And there's tons of work to do like the, the Nordk report, I should be really clear is directional. It doesn't mean that we've success. We know that there's the current model with Medicare has weak incentives built in it. It's still reconciles back to fee for service. So it's not where we want it to be, but directionally we're seeing some, some encouraging momentum. It doesn't mean we're declaring victory by any source of the imagination. Understood. I think the work that you described earlier today to move from, I forget the exact word you said, but actually requiring more commitment from the participants. It's a coalition of the willing to a group of people who are excited about doing the work. Basically, coalition of the committed. Right. Thank you. I think that that's a, I think that's a good step. A very important one. Because if four or five years from now, nor was to look back and say there was savings, you could point to when you started the engagement initiatives when you started the mental health screening initiative when you started the population health incentive structure and the data that you used. But in the first years that nor is looking at, we don't really see that. We don't see that there's, and there's analytic work that one care is done and a program developed based on that analytic work to lead to savings. Right. And it's, it. I like the way that things are evolving. But to this point, it looks like the savings that have happened have happened while there's been an ACO, not because there's been an ACO is really difficult to tease out any causation either in that report or prior budgets and submissions to us that I've been part of. So I mean, it seems like what you're you're alluding to is sort of like a run chart, right? And you'd be able to do some type of regression analysis to say this is exactly what we think caused movement. We'd love to do that if there's a lot of moving parts going on at the same time. So it is complicated to do that. But I do think as you say, if we look back in time, we hope to be able to come back and say the mental health screening initiative. These are some measurable things that move because of it. And so I'm aligned with you that I want to make sure we have measurable goals. And then we go back and we do do PDSA cycles or plan to study act and really say, did this work? And if it didn't, how can we either move on from it or tweak it or find a new program that will work? And that's that's exactly right. Whether it's a run chart or a regression analysis, but some way of assessing the the impact of the efforts that you're making, right, prior to today in the presentation this morning. It looked as though on paper and through prior presentations that one care was an entity that could accept dollars from the federal government and distribute it to its members. But there wasn't the analytic work or the program development or the really the quality improvement initiatives that are seen in high performing ACOs. And so I'm very happy with what it looks like is starting today, but it was missing in the past. And I asked questions last year to try to tease that out. And I wanted to ask some today, but I don't have to ask as many. It wasn't there so much in the past. And it's you're trying to do it in the future and I'm happy for that. There's in the budget narrative that you submitted there was a quote that I came across. Despite the pass through nature of some funding streams, one care controls the strategic apportionment and design of the programs and payment models. And so I was going to ask more about how is the apportionment determined and give an example why feel like you did some of that in the presentation earlier, but it's been lacking in the past. The. Alignment of population health expectations for care coordination QI and performance improvement. All of those words are used. And they, they'd be monitored with run charts and regressions. So it's been talked about for a long time, but it hasn't been a part of what we've seen. But it looks like we might now. The narrative that was submitted. If we have somebody have a copy of that that we could bring up. If not, I can try to share my screen. I can do that. Tom just make sure you don't end up sharing the confidential version. Yeah, no, what I want to, we could just turn to table 9. On page 67. The internal goals. And they include things. Like working to share admission data. Gathering feedback informing care coordination and reporting. Engaging the network. Those things. They're measurable in a categorical sense. Yes, we did them. No, we didn't. But high performing organizations have more measurable goals. Particularly things where we spend a lot of money. Right. It's we like more measurable goals. Those are really kind of mushy. And as an as a regulator, looking at your budget to this is what you're hoping to accomplish. It's a big budget for things that. You're going to be able to say, yes, we did work to develop and support. I think you'll find that our 2024 goals, member Walsh are very much tailored to what you're talking about. And our very specific measurable actionable. We heard your feedback. We also got a lot of feedback from our participants in our board and that's what we intend to present to you for 2024. We're just waiting on approval from our board at this point. Okay, great. I after this morning, I trust that you'll do it. So. I'll cut short the questions about nor cut short about narrative. I'd like to talk a little bit about risk. And specifically, we talked a bit last year about the risk corridors and the potential to earn more in savings. If there was greater risk. And it seems looking over the years that the amount of risk, any entity, whether it's you as the ACO. Or hospitals or. Primary care providers, the amount. Of risk that is accepted has kind of stagnated. Is that. Am I reading those reports correctly? Or have I missed something? So to go a little bit through time, because it has evolved over the years. We started our journey as a risk bearing ACO with fairly wide risk corridors back in 2018 and 19. I think the financial health of the healthcare industry was very different at that point. It's still scary. Frankly, the entering department was that much financial risk. Once the pandemic hit, we thinned out the risk quarters a little bit because there's so much uncertainty around healthcare costs. I mean, when it first landed, we weren't sure if healthcare costs were going to go through the roof. From the pandemic and actually went down the other way. So. We, we thinned out the risk corridors in that period to really protect the providers from an. Unfair result and scan it down while keeping some. Awareness total costs, total health your costs. Emerging out of the pandemic. We took a moderated step and increase the risk corridors to where they are now at 3% for the public payers, Medicaid and Medicare. And we discussed the risk corridors with our finance committee and the board and. There was general agreement that sustaining the same level of risks risk, which is still a material amount of money in my view felt appropriate for the current time. This is something we reassess every year. It's also a negotiated term with our payers. We're trying to find a balance from both parties. Yeah. Yeah, I appreciate that. And the, the pandemic year exactly right. The, the panic at the beginning about what. What may happen versus what actually did is. It's another reason that finding causation. From the norc report or any other is very, very difficult. Right. It's everything's kind of swamped by those. Those those types of events. The, the per member per month. Payments CPR and PMH. Those are in my understanding are meant to help or stabilize. organizations and help them transform. Help them make the changes so that they can move away from fee for service. So I just like to suggest going forward. It's been seven, eight years of organizations getting transformational dollars to facilitate transformation. And one way that we would be able to know whether transformation is happening or not. Is comfort with additional accountability. Which would show up as accepting greater risk. So the purpose of those advanced payments was to help provider organizations. Get ready to be more accountable. So we would see more accountability with greater acceptance of more risk. So that's something that I want. I'll be watching. And for in the future. I think. We're looking to get away from fee for service payment models with FQH she's by piloting a CPR like program on the FQH she side and. As you're most certainly aware, you know, a lot of positioning has gone on to have hospital be ready to take on global budget risk. And I think we've laid a lot of successful framework for that and will continue to do so. You know, Mr. Boris mentioned earlier on our efforts to expand the Medicaid programs such that not just attributed but but all all Medicaid payments would run through essentially an upfront. All inclusive payment. Those are all consistent. I think with what you're talking about increasing the risk level. It's complicated. We try to moderate that with making sure we can sustain the network. Over time and not sort of force feed this too quickly. So. It's it's a balance. Yeah, we hear you. I feel. I feel heard and listened to I appreciate that and I'm trying to hear. Listen with you all and. Work through this because as you've said, and I've said, and I believe we're we're trying to do something that's helpful. To as many people as possible. I think. Given the length of the runway that we've had with with this approach. I would like to see as a as a regular for the money that's been spent. That there's greater risk accepted. That's a signal of of the transformation happening. So this is something that I'll be looking for. And thanks for bearing with me. Well, you. This morning's presentation was unexpected. I'm kind of jumbling my notes because of it. Yeah, we would like to be able to tease out, you know, one of the things. And kind of what I had thought I would be saying to conclude. The idea of having data analytics that informed the design of programs and incentives that lead to improvement in the data where our performance was lacking. That's kind of what. It used to be a medical service organization now and accountable care organization. That's the service those organizations bring in addition to passing through the dollars. In order to be able to say that that organization is producing those changes. We need to have that type of structure where we can see the analysis. We can see the program design. We can see the change. Those are the things that you're talking about today. And without that, we really can't. See where the organization has caused a change. And the North report does a nice job, even in the abstract of saying this, it says that yeah, there were Medicare savings. But Vermont has a unique and robust history of health reform. And the potential effects of pre existing care and delivery systems initiatives may have led. To the changes that we see, we can't just say that it's the that it's that it's the ACO. And so as a result, unaccounted for differences in area level characteristics between the comparison groups can affect the accuracy and precision of it. So, without that focus on being able to show some causation, it's really hard to say that the money being spent is leading to changes. Earlier today, you described an approach that can answer that question. And I'm encouraged by what you presented earlier. And I think I'll leave it at that. So thank you for what you presented earlier and thanks for answering my questions. Thank you. I have a couple of questions. On page nine of the narrative that referenced some top performing ACOs that one care had contacted. And I was curious. Two things one, who were they and what were you trying to carry over from your learnings through them. Am I permitted to name them. I don't know. And then in public. To tell you, though, I know the names. I can talk about what we discussed a little bit. If that would answer your question. That's fine. Yeah. So some of the discussions were specifically about ED utilization and access to primary care because those were the two benchmarks where we scored low. And so we had discussions with three total high performing ACOs about these particular areas. And also about patient experience because we identified that one of them in particular was doing pretty well on their cap scores. So we wanted to find out how they were doing that. So we had we had great conversations. We have more meetings to go. We usually we only get about half an hour with these people. They're busy. They're like CEOs of ACOs and some medical people too. But we heard great stories about things like care management in the ED and building a robust system for that. Building on the team based care idea so that patients are getting more accurate help with medication reconciliation. So employing pharmacists to be on the team to do that. Also allowing non MD non nurse practitioner people to perform annual wellness visits. So those are some of the examples and I can certainly get some more and tell you the names at a later time. And just generally chair Foster. I had the opportunity to attend the National ACO conference in DC a month or so ago and it's challenging. Some of the smaller ACOs or ACOs are more focused that I mentioned on one organization. They're they're very adept at a very kind of command and control method of setting the agenda and what they want providers to do because it's largely an employed model. They're also really adept at how they handle a patient facing relationship in a way that's challenging with our model. So when we talk to them they're really interested in some of the big impacts that we've had statewide. They're really curious about that. We also presented on how we utilize waivers in a way that others haven't really even scratched the surface of. We're really curious about some of the ways they with their kind of more tight model have been able to move the needle in the way Dr. Wolfman talked about. So it's it's it's one of those things where our APM by definition is just very different from some of the other ways that ACOs have approached this problem and scale wise is different. We're heterogeneous. We're much less sort of top down command and control oriented. We're more like trying to bring together versus they're sort of saying this is exactly how you're going to do it. And this is why we're going to measure it. I'm sorry. I didn't mean to interrupt. I just wanted to add one more very important note, which is the others are on one EHR to that's a big difference. Big difference. I know we didn't we went past answering your question, but I just wanted to get a little more context. Chair Foster. No, no, I appreciate it. That's helpful. On the primary care provider learnings and the wellness visit learnings. Are any of those takeaways incorporated into this year's budget? I assume the question relates to the CPR data that I shared. Just make sure I answer correctly. I just meant in general. So you met with these ACOs and you tried to learn some things from how they're doing things, which is great. And I was curious, which of those takeaways are being utilized this year? I can answer that. Fortunately, we had enough data and insight before we got those had those discussions and got our benchmarking report to already put into the 23. PHM, the metrics that, you know, if you succeed in them, you're increasing primary care. And if you exceed in them, you're reducing ED visits. So we already built that into the 23 model. We're carrying that forward into the 24 model. So the benchmarking findings were not a surprise to us. We had already discussed. We expected those findings and we had already built them into 23. And going forward, we will continue to learn, use the learnings from these discussions with other high performing ACOs to help us with our strategies to work on those measures in particular. And then, Mr. Boris, I think what you were about to say is something I was interested in as well. The CPR program and how you adjusted it. Please, I think you said you were going to say something about that. Sure. So the data I shared about the CPR practice performance is really just intended to show our process a little bit. These are brand new data. We're just kind of making sure we understand them entirely as well. But how we can use a program like CPR to engage with the practices in a group setting where they can all share ideas. They all have different perspectives and ideas and use that group to really help understand some strategies moving forward. And then we can measure and monitor and hope to see some different results in the future. So just I want to make sure I'm clear on the CPR program. Is the total amount of money available to independent primary care providers greater or lesser than in last year's budget? It is greater in total. We've advanced that percent of total cost of care from a max of nine up to 10. That's some substantial additional funds. Now it must be said attribution does play a part in this because we, you know, our work is contained to the attribute of population that is a moving part. But I anticipate that it will be extra money for these practices. So in terms of percentage, absolute dollars and amount per practice, you anticipate will be greater. I do. We can confirm that once we get final attribution from the payers over the next couple of months. That will really be what lands that and I'll be able to give a more conclusive answer. And is the. So the goal I saw by 2027 was to move that percentage to 12%. Are there any reasons why you couldn't move it to 12% now? It's. I mean, technically, no, but because of our network configuration, I think it's important to take a step wise approach. One year really doesn't generate money outside of the payer contract revenues or the hospitals. So when we increase the percentage to primary care comes at the expense of somebody else within the one care network. I just think it's appropriate to take a moderated step, tell everyone where we're going and kind of move in that direction year over year. I think that's a better strategy to sustain the one care network if we're too aggressive in these kind of investment areas, it risks losing participation from from the hospitals in particular. And if I could just add, you know, I mentioned that other ACOs tend to be a bit more top down command and control. One care is its participants. So the way Tom makes that decision is he has an advisory committee to the finance committee that deals with diabetes care arrangements and asks them. Where's your sense in terms of our pacing? Should we move faster or slower? Then that comes to the finance committee to take a vote on. Is this the right thing to do as a representation of our entire network? Then it goes to the board for approval. And what was really interesting, I would have thought the finance committee, which has hospital representation at the hospital representatives would have been, you know, slow down. We're really in margin trouble. We can't put more money into this just to put the primary care. The exact opposite was true chair Foster. The hospital representative said, we want to move as fast as we possibly can move because we know that in the end, this is the right thing to do to reduce overall total cost of care to get more money to primary care. So it was really heartening. But again, I just want to stress that we are our participants. We don't make top down decisions and tell them how it's going to be. We rely on them to work with us to make collaborative decisions across the state. I appreciate that distinction. Did you ask them to go up to 12% and they said no, if they were so supportive, why are we at nine not 12. We asked them what the right pacing one is pacing was and as Tom said, they felt that stepwise approach was the right way to go. There were a few, you know, there was variability, right? There was discussion about how fast should we go and should we push faster. But the general agreement and trend had been to get to 12% by 2027 and they decided to stay with that goal. Kind of despite the financial headwinds. Well, I think the whole, you know, the whole everything everyone's working on through this in the next all pair model work is really to drive some of this more money upstream because it will alleviate some of the financial pressures on the hospital. We agree. Completely. We agree. Do you think there's any opportunity to go and push your network to see if they would go to 12% now? Tom, I, you know, we'd have to go back I think with the finance committee and the board and take another vote based on that feedback, but it's possible to do that. Yeah, I mean, you know, given sort of the trajectory on the benchmarking of the as you guys. To your credit acknowledge. I do think there might be opportunity there to get that higher and the hope would be and if we're sort of looking towards global budgets in the all pair model to. This might be a nice on ramp for an opportunity to see how this works and alleviate some of that. Goal comes to fruition. Then I think it really is an important point for the next reform efforts. So I think it'd be worth the discussion. And if they're so supportive of it. Well, it's more than nine. Well, we appreciate the feedback. Page 16, I think he spoke about a little bit. Some of the drop in primary care practices. 234 there's six from 2022 to 2024. Have any of the ones that have left come back like the ones from 2022 or 2023. To my recollection, we had two primary care entities that had left for a period of time that have returned. They have several that have closed. Well, this might be a point for your network about the right level of funding for this total cost of care for primary care that you had a couple close and then second on page 31 of the presentation. 41% are using the CPR money to exist current operations, not expand right so this is like a lifeline, not a enhancement. You know, the fact that you had to close and you lost them from your network and 41% are using the money to sustain themselves might be a good argument that maybe 12% is better than nine. I'm not sure if I could just clarify. I think you're making an excellent point and a couple of the practices that blows were a result of retirements. Just wanted to make that point. Sometimes more money keeps people in the game. Have you guys reviewed the vitalize submission that the board's received. We have not. Right. Do you know whether or not you've lost any primary care providers to from your network to vitalize. I don't know if you know it, but off the top of my head, I don't know the answer to that question. We can definitely get it. I don't verify because I don't know enough about vitalize. We did lose one participating attributing provider in one payer program to another ACL arrangement. But I can't say if it's vitalize or something else. I think you should take a look at their submission and what they're doing on the primary care front because it's it's quite robust. And it may be something to look at and think about in terms of, you know, if you can match it or do something similar or whether or not it presents a risk to whether or not you lose primary care providers to because of what they're doing. And of course, as a regulator, we're agnostic as to where. Providers go, but I think there's really some innovation there that's going on that might be good to take a look at and consider. Happy to do that. Great. I want to go. There's two comments in the submissions about the cost shifts. This page one of three. Of the narrative. This is in response to a question about what actions healthcare stakeholders can can take to support the ACO to achieving the goals of the all pair model. And one of the lines said that quote this could begin by finding common ground around belief systems value based care recognition of the cost shift and affordability. And there seems to be a little bit of a bait in the state. About cost shift and I wanted to understand your views of it and what the common understanding is that that you thought we should all have. Tom, do you want to start you would like me to start. No, I can, I can give a start, but I think there's a lot to this question. You know, the topic of affordability comes up often and I sympathize with this board because it is a big challenge. My personal opinion is that the cost shift cost subsidization, whatever terminology. We use contributes to different dynamics of affordability and I think we should all be kind of open and discussing it as a system as a state. And we make sure that the underlying kind of economic design of how health insurance is structured in the state or nationally, frankly, is in support of our Vermonters many of whom, you know, financially don't have a lot of means to put into health care. So I think it's a really important concept I've been, you know, my personal opinion is I think the cost shift is a real challenge in Vermont. There's a lot of reasons behind it, but I think it's a big challenge and I think we should all be working together to try and address it. So I think that's kind of where I started. I think that we just, this is a really interesting complex and problematic dynamic that goes on for a lot of different reasons and it's going to take a very coordinated effort to help address it. And what, what is it in your view. And to me, it's, I mean, this is an upstream component of our budget. So we live without whatever dynamics are in place, but I think that there are differences in the insurance coverage landscape and over time we've seen differences in the rates that payers pay for public insurance lines versus commercial. And I think that is putting a lot of pressure on those who have to purchase a commercial insurance product. And I just say, you know, in terms of cross subsidization, I think that the current model and the existing incentives that are involved with it are aligned to promote health care versus sick care. We know that, right? They reward see symptom treatment and not illness prevention. You know, we're trying to shift that payment model. But when we know that certain aspects of care under reimbursed under the current payment model, including primary care, mental health, post-acute, you know, home health care, I could go on and on. And there are incredible challenges to integrate work around the biggest challenges that we face as a society, mental health and substance abuse, housing, workforce, you name it. It's a real challenge. And to get back to your question about the cost shift or cross subsidization, we know that we're not putting the right money in an equitable way from all payers into what will actually drive the best possible results. So I kind of pull a camera back, Chair Foster, to say, what do we as Vermonters, if we have a certain amount we want to invest or we're able to invest in health care, how can we get the best possible quality outcomes for the people we serve in an equitable manner in a way that we can afford? Right now we know that we rely heavily on unit cost from commercial in this system to offset utilization in government payers, right wrong and different. That's just a fact of life. Now, I think what we want to do is lower the total cost of care in total so that we improve that slightly. But I do think we need to think about how we're investing money at a level below that within each payer into the right things. That's some of the stuff we've been talking about today. But we have to acknowledge that we do, you know, like all insurance systems, you generally cross subsidize those who are higher need from those that have less need. But in this case, the amounts that are coming in on a unit cost level are just very disparate amongst the different payers. And affordability is obviously, as you know, part of our mission here. 100%. I'm a Vermonter, right? So this means a lot to me. It means a lot when my friends come to me and say, I don't understand what you guys are doing at one care because my premiums keep going up. And it's a longer discussion that, but I agree at the end of the day, healthcare has to be affordable for reminders, no matter what coverage you have. We are relying with you 100% and we support the board in that mission. Great. And that's appreciated. When you say common ground belief system around affordability, what does that mean? Are you referencing a specific question? Well, as referencing the answer at this page 103, it's about the question to action stakeholders can take to support the ACO and said this could begin by finding common ground around belief systems of affordability. But I think some of that goes back to a commentary we've had earlier or discussion we had earlier here, which is one of the reasons that I think we struggle is there's some debate about whether value-based care works. And when that debate starts to surface, it sort of destabilizes a lot of these efforts. And further, when there's discussion of whether there really is a cost shift or whether there really is cross-subsidization, it tends to take away from some of the credible efforts that there are to actually remediate that cost shift and start to balance it in an equitable manner. I don't know. We should read too much more into the response than that. I mean, Tom, I don't know if you want to comment on it or anybody else wants to comment. But that's how I take it. It's really just trying to acknowledge that we've got some systemic problems and that we're taking steps to try to remediate those in ways that, you know, we're not policymakers. So we can't like shift everything, but we're trying to work within the system we have to try to alleviate some of these things that are problems. I did want to talk a little bit about the NORC report. Mr. Bermuda mentioned we should invite NORC. I just want to let you know we have, we did invite them while they're not able to attend. That's not great. Yeah. So we won't be hearing from them. Am I mistaken that they did, they did present back in November of 2021 when they had the first report? Is that right? I believe they had in the past. I wasn't here, but my understanding is they had presented in the past. Did they provide a reason why they are not available? Is it just logistics or are they not permitted to report out? I'm not that close to that. Okay. So I did want to talk about that report and I had read that op-ed and I actually had the same sort of takeaway as Dr. Merman because it did talk about Medicare savings as I think we all know Vermont's the least expensive state in the country on Medicare. And so I was trying to wrap my head around why do we want to save Medicare more money if we have really exploding commercial rate increases? I think that's a fair question. At the end of the day, that was how the APM was constructed, right? It's a reconciled model back to fee per service. So if savings do accrue, they accrue somewhat to providers, but a portion of that goes back to the payer, Medicare. But I do think we need to move away from that and move to an unreconciled model. I think we need the maximum appropriate level of funding from the federal government into a small state like Vermont if we're going to be successful in these efforts. Well, so under the cost shift theory, as I sort of have understood it to be told to me, wouldn't saving Medicare money be a negative for Vermont commercial insurance payers? I think it depends on how those savings are achieved. So if our efforts are reducing total cost of care, not necessarily. Do you have a sense one way or the other, whether or not these savings, I understand the conceptual aspect of that, but whether or not those savings from the op-ed or the Nordk report are of the ilk that are saving commercial money or not, or you're uncertain? I think the report was only referencing Medicare. And again, my commentary in that op-ed was very much related to the framework laid out, which is directional within that report. We've saved money versus what was expected expenditures for Medicare beneficiaries in the state of Vermont, which is what we set out to do when we entered that. I mean, this is a collective week. That's part of the all-payer model we set up to do. Totally. Yeah. No, I get that. When that's the right thing long-term, I don't know, but that's what we set out to do. Right. And so what I'm trying to understand is if there's this cost shift where Medicare doesn't pay enough and it gets shifted to commercial, wouldn't saving Medicare money be a negative for Vermont commercial insurance payers or we don't know in this context? I think it's hard to sort of make that logical jump from, again, a directional report to saying, philosophically, yes, we want as much money to come into the state as possible, but the way in which that money comes in from CMS is really important. So we don't want it to be based on we're doing unnecessary procedures or providing low-value care. And we know in some other states, and this is not to malign them, that there's a tremendous amount more spent than a per-benefit sheet per year basis. And they don't generate better outcomes or quality measures as a result of that extra work. So we're not looking to generate money that way. I think we do need to enter into a system, whether it's the AHEAD model or any other model, that gets the appropriate level of reimbursement to help offset the infrastructure expenses of providing care for a large population in Vermont. So I'm trying to answer your question if I'm not, I apologize, but I agree. We need the right appropriate level funding come in, but it's got to be for the right reasons. It can't be because we're driving up unnecessary utilization. Right. I understand that. Okay. Really briefly, I think, Mr. Boris, you had mentioned sort of the historical savings versus target and the other programs. So I think we have a good sense of Medicare. He said Medicaid was losses in 18 and 19, shared savings in 2021 and 22, and on target for 23. Does on target mean achieving savings or break even? What did you mean by that? Our projection is very close to the target. These are big, giant numbers that we're talking about. So it's possible that we'll land on either side of the line and once 2023 concludes. So I'd say we're turning very close and I don't really want to commit one way or the other just because there's still a lot of the year left in terms of claims data coming in, but very close. Would it be possible? I looked on your website and I'd seen some charts, but so maybe it's available, but I'd really love like a chart of here's year 2018, 2019 through 23. Here's the target. Here's the savings. Here's the risks. Here's how much we saved. Here's how much went out for each of the payers, you know, because I think that would help sort of digest this. So for Medicaid from 2018 through 2023, let's presume you hit target this year, which is flat. No savings. No losses. Would you be how much money would the one care program have saved on Medicaid? If you don't have it, we can get it later. I do actually about $12 million. Then is that how much was paid back out to providers as savings? Correct. Yep. And then what about on commercial? Commercial has been a more challenging line of business for us. There's a lot of movement in the commercial spaces, you know, from the insurance rate review processes. We have had some years of savings and some years of losses and in particular through the pandemic really narrowed down the savings and loss there. But I can give you a quick estimate. I think we are roughly 357,000 to the good in those programs. So relatively modest relative to the other programs. Again, that's how much was paid back out as savings. A little bit of nuance that actually in that the pan during the pandemic years, 2020, 21, and we structured the commercial arrangements that there were savings and loss, but they were structured as reinvestments in quality work. Rather than a shared savings or shared loss distribution, but conceptually, you have it right. I had this thought last year and I feel it again, this year, which is like the risk corridors are so low that if overall things look pretty good from a savings perspective. It's financially beneficial to have more risk and the crux of the program and you're much more initiated this than I am, but it's risk. That's the crux of the program. Why are we seeing low risk corridors, especially when there's a history, at least on Medicare and Medicaid of, of what you described as good savings? Yeah, really good question. You know, risk is something that comes up in all of our lives and it's, we have to be prepared for the bad outcome. And when I think about these programs over again, I use a multi-year thought on it, we have a line like this that this is ordinary healthcare inflation. Healthcare costs go kind of like this relative. You might have a couple of years with really good results and you might not. We hope our work more consistently lands on the positive side of the line, but I cannot promise any hospital CFO or anybody in the network that you will not have shared losses in a year. It's going to be dependent on how well we do our work royally in this case. So as part of this process, we need to communicate to every entity that bears risk. What's the potential? We call this the maximum risk limit for any organization. We give them a number to say your downside payment will not exceed X. That number is often scary to these organizations and that a small critical access hospital. This could be betting their whole margin for their year. That's a challenging spot to put an organization. Can I just cut you off Tom to talk about that? So when we think about risk, providers balance sheets, specifically hospitals in this case that we're asking to take risk on behalf of their healthcare service area, aren't designed to deal with insurance risk. And as Tom mentioned, insurance risk goes up and down, right? It's not a linear trend. So insurers have reserves built up or mechanisms to offset that risk that hospitals just don't have. So I agree with you, Chair Foster, we want to get no place where more risk is there, but it's the two canoe problem, right? We've got to get them out of the risk of not having enough volume and into the risk of having the wrong kind of volume and too much of that volume. And when do we hit that inflection point? That's the question we need to all address together and figure out how to ramp up into that risk and where we kind of tilt over. But as part of that, figuring out how to help them mitigate that risk over time or somehow reserve against it that they're just not set up to do today. And it just seems like the odds are favorable. So it's not like it's not dollar for dollar. You multiply the likelihood of an outcome by the upside of the outcome. And maybe I'm more of a risk taker than others, but it seems favorable. As Tom said, it's a little bit when the margin is this size and the potential maximum risk is this side, they feel like they're betting the farm. Or they're doubling the farm with 70% odds. I appreciate you bringing that up. I often end that voice with the hospitals. So I very much aligned with this. There's an instinct or a natural inclination to go to worst case scenario. And I often try to remind the providers there's a best case scenario where we do really good work together and you can capture these savings to reinvest in the future. So I appreciate where you're coming from on this. Maybe just two quick topics. The primary care money for hospital based primary care providers, the PHM money, we'd asked about it. There was a lack of certainty as to whether or not it had been used for primary care. I think at the last hearing back in the spring. Do we have any further insights as to confirmation that that money was used to support primary care? As part of our ongoing work there as we explore this, I've had a number of conversations with hospitals to really get an understanding of how they've utilized these funds. And I can say at a high level, I'm very pleased with what everybody has said. They've really what happens for many of these hospital organizations is the funds they get from 1 care are pulled with other resources such as blueprint funding. And they use those funds throughout their organizations to support the cost and quality improvement efforts that they are contracted with us to fulfill. So I've been very encouraged and pleased with how these hospitals have used the funds. A lot of it goes into things. For example, like care coordination work, hiring nurse practitioners for behavioral health, things like that. So really happy with what I've heard from the hospitals. And what steps are being taken in connection with this year's budget to ensure the money is being utilized appropriately for primary care at hospitals? I wouldn't say it's necessarily a specific component of the budget per se, but I really anticipate having ongoing conversations with the hospitals and an understanding. I think that there's a great story to tell if we ask the question of them in the right way. No, and sure, chair Foster. I mean, we've made efforts to gather the information that were related to the order to. To this effects. You know, our contracts don't require that hospitals use funds derived from participation in these programs in any specific way. So it's something we're going to need to work on. And, you know, like, I understand you're interested in it. As you know, there are other components of the order that have caused us to challenge that order. So I don't know how much more we can really say about it than that. Yeah, I'm speaking really about going forward and how we're making sure the money is going to be where it should be. I recognize one care is appealing the order about getting affidavits to ensure that the money went to where it was supposed to be. And I recognize that. But a big crux of the program is support for primary care. And it's really important if you want to do that to make sure that the money's. Going to where it's supposed to be going. Otherwise, it's not going to work particularly well. And when we do see the downward trajectory and some of the primary care benchmarking that highlights that concern for me that we don't know where that money really is or have really. A clear accounting or steps in place to make sure it goes there with this money this year in this budget. And do you have counsel on by chance? We do have Aaron Perry who's our in-house counsel. Nice. Great. Nice to meet you. I'm going to ask a couple of questions just around executive compensation. I don't want to get into the litigation, but there's some questions as to this year's budget that are relevant on that. So we have an administrative cost here a budget and we have executive compensation in it. Am I correct that executive compensation has been lowered in this year's budget? Sorry, not for the lawyer for a witness. We have budgeted the existing compensation structure for all of our exact executives in 2024. I thought it was lower than in 2023 now. There's always changes in terms of positions. I just go back and look at the staffing changes through time and we always build a budget that has certain assumptions in and sometimes those pan out exactly as planned. Other times not. So there's some nuance and moving parts to it, but the same structure exists in 24 as it did relative to 23. Yeah. And again, just restate, we built this budget from the ground up. And as Tom said, the actuals last year may have had some noise in it from other things in terms of comings and goings of folks, but the budget we have represents our new budget. Expenses for next year. Okay. I don't think I have anything else. So thank you all for the submission in your presentation today. Anything else from Miss Sawyer or any other board members? Great. I'll turn it to the healthcare advocate. Thank you, chair foster. Just wanted to thank the board and particularly board staff, Michelle, both Michelle. Russ and Angela for the work on it and also to one care for the presentation and for the narrative and all the work you're doing. Just as a roadmap, I mean, most of the questions that we have track from the narrative so I can cite that if you folks want to pull the exact quote, but just to start off. This is actually from your presentation on slide three, you made an assumption that there's going to be a slowing of Medicare Advantage migration. And I'm wondering why you think that that's a safe assumption that it seems to contradict what we've seen in terms of penetration over time from state data. Sure. Happy to answer that. Firstly, it's just an estimate or a forecast based on some data that we've seen. We get each year. An initial roster of all attributable Medicare lives and then we know how many can move off to Medicare Advantage. I'm happy to supply the data if you're interested. I view this as a regression to the mean. And that we expect Vermont has been slow to see Medicare Advantage adoption. So I anticipate that there's a pretty aggressive period that we've lived through where the Medicare Advantage penetration has increased. But at some point it will taper off in my estimation to more like what the national average is. So I don't think we're going to see growth in the Medicare Advantage penetration just in perpetuity. Otherwise, that would mean everybody's there at some point. Yeah. If I could just add to that. Medicare also publishes those numbers. You can pull them down from CMS and CSV files. And it's pretty well known that the Medicare Advantage penetration was a little bit softer than expected through open enrollment last year. And folks were just theorizing that where, as Tom said, Vermont was probably low in terms of Medicare Advantage penetration relative to other states. They predicted a very quick uptake that's been slower than was expected in those initial analyses and forecasts. That's what I was kind of referring to as well. I know we've spoken about this before, but I'm wondering how you reconcile this assumption. And if you see it as a competing priority that your parent organization has an MA plan, like do you do that as a threat to what you're trying to do or is it not a threat? That's right. So our parent organization, the sole member of OneCare is UVM Health Network, they have an affiliation with MVP for UVM Health Advantage. They don't have an ownership stake in that plan to my knowledge. I think their overall approach to the 65 plus population is really consistent, whether fee for service or MA. And they're trying to build a lot of the capacity within their population health service organization in coordination with us to do a better job managing it. I don't really know that I can opine on Americans have a choice as to whether they want to do Medicare Part C or they want to do traditional Medicare. Within Medicare Part C, they've got choices of who they choose. In my mind, it's not our place to sort of comment on which program or plan they choose within that. Okay. Fair enough. Fair enough. And this is from the narrative, page 54 and 55. You wrote that the aim to reduce possible participation fees over time has been offset by regulatory directives to move money between provider types, purchase benchmarking tools, provide analytic reports unrelated to ACO activities, answer questions about concepts unrelated to when it cares ACO contracts and defend the value providers read from being in an ACO under state level arrangement. These regulatory variable costs have significantly increased resources and cost operating ACO limited resources away from supporting your mission. I'm paraphrasing a little bit there. That's okay. But your budget submission, as I'm trying to reconcile this shows an 11% reduction of participation fees from the hospital. So I'm wondering how you can then argue that these reductions were offset by costs related to regulatory directives. And I'm wondering which ones you're referring to. Good thing. So I think the comment was largely related to the past activities, not necessarily this 2024 budget that we've submitted here today. It's hard. It's hard to show this, but a lot of one cares work really is in this regulatory space. There's a lot of reporting that we do. We've ordered been ordered to fulfill this benchmarking report that comes with significant costs, but also tremendous time effort from our staff. The evaluation works similar, not necessarily saying these are bad things, but they have added cost to our existence and the greatest cost to me isn't the money. It's really the effort that the effort I'd much rather direct towards our providers towards the work that we presented today. That to me is where the real value of this structure is. And I'd love to see over time us being able to take some of the resources that currently go to those areas that you mentioned and put them into our provider network to drive the change and the improvements that we hope to see. Thanks for that. Could you specify what analytic reports you think are unrelated to ACO activities? I think some, the benchmarking report is one that comes to mind. Not that it's entirely unrelated, but I think it's at a different strata. Our work is much closer to the ground level. We're trying to do practice level work, measuring performance within a primary care organization of things like annual wellness visits or depression screenings. It's really a boots on the ground type of model. And some of these other reports to me are way up here. And we've talked a little bit about causality today. I think that's where I really struggle with it is it's just hard, if not impossible to prove causality between anything that one care has done and what you see on those high level reports. So that's kind of what I mean in that. Okay, that makes sense. I mean, that track of what you said. I mean, the next question is about what you said about the benchmarking report. And I'm not saying you said this, Mr. Boris, but in the narrative. It reads on page 100. While the benchmark report supplies some interesting information, it's better reflection of macro level dynamics and capacity issues. It's a tool for regulator, not for an ACO. I'm wondering how you arrived at that conclusion that it's only reflective of macro level dynamics and capacity issues. Because I mean, at the board, I think many folks spent a lot of time, you know, developing an approach to this benchmarking. And how do you make that determination that it's not due to potential areas of improvement within your own organization. I really think that at that strat, that super high level, what we're seeing is what exists in Vermont. If there's low, you know, skilled nursing facility usage, it's probably because there's lack of skilled nursing facilities and access. And one care could do excellent work with a distributed population and generate really good results under its contracts and for the patients that are served by one care providers. It may never actually show up on that report. It's, you know, relative to the whole, the whole, I mean, there's, I don't even know how many claims go into any one year of that benchmarking report, but I just struggle with using it as a measuring stick for whether or not we're successful in our endeavors and think that we should be using much more kind of focused measurement that gets at our programs developing the results that we'd like to see. Okay, chair Foster asked about this quote, so I won't read the full thing. It's on page 103 about, you know, you talk about the regulation should be rationalized and ensures empowered capable and focused on fundamental levers that can help control costs, increase access, ensure high quality care for the monitors. I'm wondering, what do you mean by rationalizing regulation? Was question one under section nine on page 303. I don't have the narrative. It's around coming ground. Yeah. Yeah. It's page 103 under question two on that page, which is the question was what other actions can health care stakeholders be taking to support the ACO and achieving the APM goals. In the quote, I think it's the last sentence I think in number two on 103 is that that's what you're asking about. Yep. Yeah, I want to read the whole thing. I've been reading a lot of quotes. Yeah. I mean, I think in totality, again, we are 100% aligned with the goals of the Green Mountain Care Board. We want to see this succeed. We're just trying to find the right Goldilocks sweet spot of how to how to work with the regulator to get the best possible outcomes and not have work that doesn't end up being productive or doesn't really, as Tom said, it's a blunt instrument that doesn't really measure whether we've been successful as a participant network and as an ACO and getting this work done. Okay. Um, the second one other part of this question is that you talk about fundamental levers to control costs increase access and ensure high quality care. What do you think those fundamental levers are? To me, it's what we've included in the budget, which is really working with our providers to ensure that they're, they're adhering to best practices in the population health domain. And making sure that things like care coordination are uniform across all providers. We're using data to help inform changes and how care is delivered in that primary care setting or community based setting. And all of that work we believe through this budget will help ensure high quality care for Vermonters over time. I just add that, you know, fostering collaboration around particularly transitions of care is a really huge thing. Right. We know, if you think about a Pareto right in 80, 20, we know 20% of the population is driving 80% of the spend. So how are we identifying those, those potentially high risk. Rising risk and high risk patients and creating a patient centered alignment of providers around them such that we can help them navigate their disease state and other things that they're facing from a social terms of health perspective together. That those are real levers for success. Right. Thank you. I appreciate that. Switching topics a bit because I don't think we've really touched on it much today regarding the UVM data analytics contract. I'm wondering what outcomes or improvements Vermonters should expect from this relationship and how you're evaluating that or thinking about that. Thanks for the question. I think that there are some interim outcomes that we can focus on. The first one we've talked a lot about today is the cost savings in the budget of over $800,000 through some of the efficiencies in changing the data platform. I also think that it will be realized in the better access to critical information that the provider network has. So having that timely information and being able to get access to patient lists. Information of individuals that might need preventive care or follow up care and being able to have that in a more timely manner and facilitate better health care outcomes. Ultimately. So those are 2 of the things that we've really been focused on. We do have some metrics that we're looking at around timeliness of completion of reports and accuracy and those sorts of things. They're all looking good so far and a lot more that we need to collect as we actually move into the new data platform around the satisfaction of providers. Anyways, there are a couple things to facilitate the goals that we discussed today in the population health model mental health, etc. Okay, thank you. Just want to touch on a couple of quotes that you had in the narrative around spending. This is from narrative page 8 and 9. You said one care quote one care findings included low inpatient facility spend across all measure years, which included low inpatient rehab spending. Low outpatient surgery spending. And then you concluded these findings indicate a very low cost of care provided by one care. ACO network and clear evidence that the ACO does well and keeping individuals healthy and out of the hospital. Are you assuming that lower spending keeps more people healthy. And if so, is that true across the board or is there some nuance in that assumption? I mean, I don't think anybody would say that lower spending equals better health. I think it's again, how we utilize the dollars and the most efficacious way to get high value care. If we can. Care for people outside an acute care setting. That's always going to be the preference if it's the right place to care for them. And there's a lot of elements that go into clinical judgment around what the appropriate criteria are for admission. I mean, Dr. Wolfman could probably comment on that much better than I can. I don't pretend to be a clinician, but I don't think it can universally be said that lower cost means better health care. Okay. So it sounds like you would agree. I just have a statement. I mean, would you agree that lower spending could also mean avoidance of care avoidance of high cost care. Access restrictions for healthy individuals or wait times lack of providers like could it mean those other things? It could. I think that's why we use the quality metrics and the outcome measures metrics in combination with the financial measures to make sure we're not stinting on care or in any way. Shorting outcomes or access in favor of generating savings. Got it. Okay. Thank you. This is the last thing I want to say. It's more of a statement than a question. We listened to the questions from Dr. Merman about the NORC evaluation tonight. I hear blood and clear from one care that you did not intend to mislead anyone into thinking that you believe the NORC report shows one care is reducing costs. But I do think the average Ramana would read this quote from your op-ed in the Manchester Journal and reaching a different conclusion. And this is what this is from the op-ed directly. The healthcare costs landscape like most cost these days is bleak. Just as your grocery bill and the price of the gas pump seem to grow ever higher, healthcare bills are among the costs that are steadily rising. This is precisely why the transformational work of one care Vermont to reduce the rate of healthcare spending while improving the quality of care is so important. An evaluation commissioned by the federal government concluded last month that one care is bucking the trend and actually driving down healthcare costs. Our view at the HDA about the NORC report is that they are seeking to answer a research question that's of interest to the federal government. And that's about Medicare spending. And I think it's critical that we make a distinction and are all aware that spending on Medicare or any other payer is very different than what the cost that people experience, the Vermont experience. And I think it's essential to not conflate those two topics. The NORC report in our view is never designed or intended to measure and evaluate costs, particularly those by Vermonters or the public. And I think that Vermonters are much more concerned whether or not one care is lowering their costs, not whether or not they're saving the federal government money. So I'll turn back to you, Chair Foster. If I could just respond, Mr. Peach, I certainly appreciate that perspective. And if our wording came across as either untoward or uncaring towards that, I apologize. Again, we do think that the work collectively that we're doing around trying to reduce total cost of care is directionally going to serve Vermonters by reducing the cost of care and improving outcomes and improving the quality and their perception of care over time. You're right, that report isn't necessarily answering that question, but I do think that we're reducing total cost of care and changing the way we provide care and getting out of sick care and to healthcare is important. And one of the reasons I put that out there is because of the antithepity and the negativity towards the ACO, it sours people conceptually on total cost of care management. And if I could just go on for a second to say the alternative to that is unit cost suppression and utilization suppression, neither one of those result in a sustainable delivery system that delivers good outcomes over time. Getting people to work together to solve this problem is what we're all about. So I'm trying to build a little bit of groundswell around, hey, some things are working and directionally we're going the right place. We're working together as a system to try to solve a very complex problem. It's not meant to say that we've solved it or that everything's perfect. So I'm acknowledging what you're saying and I'm apologizing for any misperception from it, but my intention was to put out there that value-based care does work, but it takes time to get there and it takes collaboration across the system to get there. Thank you. I will open it to public. Actually, sorry, one other thing. Would you all send me or the board, Michelle, the methodology that was used for calculating the primary care spend, the total cost of care percentage spend, if you have a methodology that you use, if you could just send that over to Michelle. That'd be great. Happy to do that. And Chair Foster, did you, I wasn't sure, did you want us to provide an executive session or in another way the names of the ECOs that we worked with? I wasn't sure from your comments. I don't think it's worth doing the whole thing. That's fine. Just want to be clear. It was fun the first time I did it. It quickly became fun. Okay. I'll open it to public comment via the raise your hand function. Ms. Aronoff, how are you? I'm very well, Mr. Chair. Thank you. How are you? I'm well. Thank you. Thanks. So this is an issue that I've brought up before. So for folks who don't know, I'm Susan Aronoff. I do policy work for the Vermont Developmental Disabilities Council. As people in this meeting probably know, people with disabilities are Vermont's largest health disparity group. One of the things that really interferes with access to healthcare for people with disabilities is basic language access. So one of the things that One Care is required to do is send out a letter to people when they become attributed to One Care. And I don't believe the letter has changed any, but I would like to ask that whatever the current letter is to be sure that it's included in the budget materials. It's been my contention that the letter is not in plain language and does not do a very good job at all of informing people what it means that now they're attributed to One Care. For instance, the letter doesn't even indicate that One Care is a business. It says it's a volunteer that the ACO is a group of providers who come together voluntarily. So I will submit this in writing, but I just wanted to take this up, you know, when it's time for comments. I've done this many years. It's never changed. But hey, there's a new administration at the Green Mountain Care Board. Yay. So I'm hoping maybe this administration might take the issue of language access a little bit more seriously than it's been taken in the past. So this is just a preview. I will send the letter as it exists, assuming I have a current copy. If it's changed since the last time I looked at it and now it informs people what it means to be an attributed life and have your provider have a stake in the outcome of your healthcare. It's a very different relationship that patients have with providers once they're attributed providers get paid more if someone's diabetes is managed. People need to know things like that. There's a real concept out there of cherry picking and lemon dropping and people need to be on the lookout for that. So anyway, that's just the first of many issues, but I was hoping if I brought it up today that one care might take the opportunity to review their letter and maybe submit a better letter this year. One that says what one that does what it's supposed to do, which is inform someone who's attributed what it means to be attributed to an accountable care organization. Thank you. It seems like a pretty reasonable request. I don't know if there's any barriers to you doing that or if you have any feedback on that. Yeah, go ahead. I recognize the public comments aren't questions, but I'd like to comment on that. Yeah, please. I assume is Aaron off is referring to the Medicare letter that were required to send out that unfortunately the well fortunately or unfortunately the letter and all the specific wording is mandated by CMS were not permitted to change that as a Medicare as a Medicare ECO. I don't know if the letter I've received I received the letter as a state employee because I'm attributed as a state employee. So I wasn't attributed as a Medicare member. But I think that the there's got to be ways where you could insert maybe just a word or two about what an ACO is like for instance a business enterprise not a volunteer voluntary operation just things like that. We'd certainly be willing to talk to you about that. And I mean, is it a different letter for the Medicare attributed lives then for the state employees. This is Sarah. I could comment and say each letter is specific to each payer program and is negotiated to the extent that it is possible to negotiate between one parent. So there likely are some differences, but having said that we're very open to feedback. And if there are opportunities for us to change and improve within those regulations, we'd certainly be happy to discuss them and to receive that feedback from you. Yeah, on the, you know, in terms of accessibility and the way we communicate. We've done a lot of work this year to improve our website so that it meets national standards for the way that it is approachable and accessible for all. So we take that very seriously. Sarah, would you be the best person to follow up with if I sent the letter because I've received that letter both on my behalf as a state employee and also on my partner's behalf who was also not a Medicare beneficiary and we received the same letters. And yeah, I'm not sure if it's the same as the Medicare letter, but I could certainly send it to you with my requested changes. Why don't we do that? I appreciate one care willing to be in contact with Ms. Arnoff on this issue because it's a valuable point. So thank you for offering to discuss that. Thank you. Barbara Black, I see your hand is raised. Barbara Black, I think you're muted if you're speaking, but your hand's raised. You can go ahead if you'd like. Okay, sorry about that. No worries. I wear a lot of hats within this organization both within the health network. I sit on the patient advisory board for one care and I sort of got my fingers into a lot of stuff that's going on. And my role basically is to connect the dots. And that's where so many of the surveys that have been done over the years talk about siloing and how this part doesn't talk with that part. And I have been with you this group since 10 o'clock this morning. And I'm going to put on my patient hat. I am a weekly patient at the medical center. So I understand where a patient is coming from. I have been an advocate within this system for 20 years. And as I listen to you, and I know budgets, I have created huge $12 million budgets in my in my other life. I listen to what's been said and I look at all of your graphs and your numbers and how things have moved along and wearing a patient hat. None of that applies to me. It doesn't make my access to doctors better. It doesn't give me even though I do have in writing a treatment group that service my care. It doesn't make them talk to one another. It doesn't give me a care coordinator. My my internist serves as my care coordinator. And at this point he's working 90 hours a week because he's doing it for other people also. I am a one care patient. You know, and because I know how to fight for myself and I know how to fight for other people. And I also know how to make sure that they have numbers for the health advocates and all of the people that are out there that are trying to help. I'm not sure there is something missing and I wish to hell I could put my finger on it, but I can't. And in everything that you're saying I'm still hearing that there's something missing if people like me in order for me to make sure everybody's on the same page. I have to type on a computer my report and make sure it gets sent to every doctor that is on my care team. And the problem with that is that I don't have access to them. And certain times I cannot attach these to my portals so that I have to either go hand deliver it or try to figure out where it is that they are residing so I can send this thing to them. You know, and I'm thinking all this is is to make the system work for me a patient. I also sit on one of the boards for for community health. And the fact that so many of the independent doctors and an organization like community health does not have access to the same electronic records that the hospital uses is just a crime. Because it complicates my life as a patient for 20 years I've heard about patient centered care. And every time I hear it, my voice closes and my throat constrict, because when you say that it's like, I'm the patient, and I'm sitting here thinking, I've got a fight for everything that I get. I'm 86 years old. Thank God I can still get up and I can go out and join these groups and with the mouth that I have I can I can make a point. But I think about all the other 86 years old who are slightly demented who don't know who to call who don't know where to go. And so I live in a senior building. They crawl into a corner and they don't do anything, and they die. You know, I don't know, I guess I just had to speak my peace Carrie has heard this before so it's not going to come as news to her. But I just would like people like me to be considered in all of this. I hear about so many of these groups that get together, and the only person that's not in the group is the patient. One of this is about patient care, and you're not including the patient in the things that you're deciding to do to the patient. So, I thank you for giving me a platform to speak my piece. You did miss black. I think it's a really, you're exactly right. And, you know, speaking off the cuff a little bit, many of us trying to access the health care system and have tremendous problems doing so care board employees board members, all of us. And you're spot on trying to get your record from one place to another, trying to get into the doctor in this state is massively frustrating and entirely unacceptable. It's, it's, it's trying to go to getting a COVID shot or a flu shot right now, or try and go to your it's just brutally difficult. And the other thing I'd say about is there's huge equity issues in that, you know, we're fortunate to get state salaries or, you know, one carer is employed and gets benefits. But you have to take time off. I had to take five hours off the other morning to try and get a shot. And people can't do that. And I just, I personally try and I just quit. I'm like, forget it. I'm not doing this. I have to go do things. And so that point is really resonates with me because it's incredibly frustrating, especially when you spend this much money on health care. Yeah, Miss Wolfman or Dr. Wolfman, please. Thank you. You can call me Carrie too. That's fine. Thank you, Barbara, for your comments and for all that you contribute in all your different areas. The patient and family advisory committee at one care is very fortunate to have your dedication for so long. And you always say wonderful things. I agree with what you said. I agree with what chair Foster just said. I'm a primary care provider and sometimes it's hard for me to navigate the system too, although I think I probably do better since I work with it on a regular basis. But I couldn't agree more that navigating the system and having helpers navigate for people who are not able for whatever reason to do it themselves is a big area of work. And I went to an ACO payer collaborative meeting about a month ago, and it was small, but it was a lot of people from across the country coming together with innovative ideas. One of the people talked about patient care navigators as a big a really important role on their team based care. It's something that I think we'll be talking about more. And I think there's just a lot more options to help patients with transitions of care navigating the system than what we're providing. So thank you for your comments. And it's something that's always on my mind to hear it firsthand from my patients on a regular basis. Why didn't you talk to so and so? Why isn't that in your computer? Why don't your computers talk to each other? So I think it's on us to to work on these things. Any other public comment? Great. Well, thank you for your presentation today on your budget and thank you very much to our team, Michelle, Michelle Russ, and I may be forgetting a couple people, but great work and thank you one care for your time today. Is there any old business or new business to come before the board? Yeah. And is there a motion to adjourn? I don't moved. All those in favor? Say hi. Hi. Hi, thank you. Have a good day. We're adjourned. Thank you, chair Foster. Thanks.