 some scheduling. I want to remind folks that tonight at 5 o'clock we will be conducting a primary care advisory group meeting. The instructions for call-in are on our website on the Green Mountain Care Board website. I also wanted to let folks know that we're adding an agenda item for next week and it's going to be really interesting. It's a paper that recently was published. I actually don't think it's officially published yet. It's out of Nesco, which is a New England state consortium group, and what they've done is they've studied primary care spend throughout six New England states, and the authors of that paper are coming to present to us next Wednesday morning. We have a meeting starting at 10 a.m. and I also wanted to give a shout out to our own Michelle DeGree and Lindsay Kil, who are also participants in that study. We'll also be hearing next Wednesday morning from Sarah Lindbergh on the 2021 benchmark, and then we have an afternoon meeting as well. Next Wednesday afternoon and we will be discussing provider reimbursement. We have a panel and staff discussion on that. I also just urge folks to check our our website and our press release as we have added a couple of additional meetings, including the prescription drug technical advisory group. The other thing I want to remind folks about is we and the group, the staff will discuss this today after they present the staff recommendations on the 2021 ACO budget, but our public comment period is open until December 21. We plan on having a vote on this budget on December 23rd, so we urge you to submit comments for consideration of the board. And that is all I have to report back to you, Mr. Chair. Thank you, Susan. The next item on the agenda are the minutes of Wednesday, December 2nd. Is there a motion? Some of it. Second. It's been moved and seconded to approve the minutes of Wednesday, December 2nd without any additions, deletions or corrections. Is there any discussion? Hearing none, all those in favor signify by saying aye. Aye. Those opposed signify by saying nay. Motion carries unanimously. So the really the majority of the agenda today is taking a look at the staff analysis and recommendations when it comes to the Accountable Care Organization. And we're going to hear from a number of members of staff. So I'm going to turn it over now to Elena to introduce all her colleagues and take us through the presentation. So Elena Baraby. Great. Thank you, Kevin or Chair Mullen. So today I'm going to share the slides. As Kevin mentioned, we will be walking through the ACO's budget and staff recommendations. I'm sorry I'm forgetting how to display a full screen. Thank you. Okay. So today, can you see the presentation? Yes. Okay. So I'm Elena Baraby, Director of Health Policy at the Green Mountain Care Board. And I have with me Marissa Melamed, Michelle DeGree, Sarah Tewkes-Berry, Kate Hoffman, and we also received help from the GMCB analytics team. So this is really a full board effort. A lot of great insights and great teamwork to come up with these recommendations. I do want to let you know that this is really, these recommendations today are based on the information that we have received. So as you're hearing kind of the analysis and our recommendations, if there is additional information that would help the board kind of formulate its decision on a vote, please do let us know. We're happy to follow up as needed. So as Susan mentioned as well, there are other relevant pieces to this conversation that will be kind of discussed at the next board meeting as it relates to the Medicare benchmark and some other more up-to-date information. So you know, this is just a foundation and I think we can continue to build as we learn more. So the agenda, we're going to go through ACO oversight, a little bit of the background, certification eligibility verification, and then we'll talk about the budget review and go through that process, the 2021 recommendations, discuss next steps, and then open it up for questions and public comment. These are a list of acronyms that you can reference throughout. We tried to spell things out where appropriate, but so we can kind of not get too wordy in our slides. This is here for reference for anyone who may need it. ACO oversight consists of two primary processes. The first is certification. So this occurs one time and then annually we go through the eligibility verification process to ensure that the ACO continues to meet all of the requirements of the certification. And then what, you know, we will spend most of our time talking about today is the budget review and this occurs annually at the start of the program year with payer contracts and attribution finalizing the spring. So there is still that kind of delta that we expect to resolve in the next couple of months. So I think we showed this last year that you can kind of see the trajectory of the process. GMCB issues the budget guidance in July, the ACO submits certifications in September, and then their budget in October. The ACO came in for a budget hearing October 28th and then we followed up with some questions based on the budget submission as well as the hearing and have used those questions and the budget submission to produce this analysis. So the board vote should happen by the end of the year. I can believe it's scheduled terribly for the 23rd and then we would work to, you know, construct the budget order in January and February and then in spring as I mentioned before we'll look at the final contracts and attribution. And then ongoing monitoring occurs throughout the year as a result of the budget order. And public comment, as Susan indicated, is accepted throughout. You know, I think if we do want public comment to influence or kind of be considered in the staff analysis and final recommendations that we will bring back before the board, you know, I believe that is by December 21st. So it would be great to have those comments in by then. Now I will turn it over. Thank you, Elena, for kicking us off. My name is Marissa Melamed. Can everyone hear me okay? Yes. Check those out. Yes, thank you. Sound check. Again, my name is Marissa Melamed, Associate Director for Health Care Policy with the board. I'm going to walk you through the Certification Eligibility Verification for FY21. So one care was certified in 2018. Continued eligibility for certification is verified annually. One care remains certified unless and until its certification is limited, suspended or revoked by the board. If the Green Mountain Care Board determines that one care is failing to meet one or more certification requirements, it may take remedial action, including requiring one care to implement corrective action plan. Over the past several years we have worked to align the timing and process of certification, verification with the budget review, because of the overlapping criteria. We issue a certification eligibility verification form in July along with the budget guidance and the form is due back in September to give us a jump on the review in anticipation of the budget submission that we receive the following month. The form verifies that the ACO continues to meet the requirements of 18 BSA 93, 82, and Rule 5 and it describes in detail any material changes to the ACO's policies, procedures, programs, organizational structures, provider network, health information, infrastructure or other matters addressed in sections 5.201 through 5.210 of the rule that the ACO has not already reported to the board. As I mentioned a lot of the materials overlap we use but we use the budget to help us verify the criteria as well as the certification form. And all certification verification materials as well as budget materials are posted on our website at the link on this slide. You can go to the next slide. The next slide is mine not caught up. Should not be slide 8. It should be slide 8. I'm not seeing it on the screen but if everybody else is I'll continue. There are 16 statutory criteria for certification in section 93, 82 at crosswalk to the 10 sections of rule 5.0 the Green Mountain Care Board monitors that the ACO meets these criteria. The certification is primarily a policy review earlier or more frequently as policies are reviewed and updated by one care staff review new and updated policies relevant to these sections and we're going to go through those in the following slides. We collect the policies annually quarterly or as soon as they are approved by the One Care Board of Managers as needed. You can go to the next slide which should be slide 9 for some reason I'm not seeing I'm still seeing slide 7 on my screen. We're up to 9. Just your side. Okay something well I'll keep talking because I have another version but I'm in the wrong thing hopefully it'll catch up. So on slide 9 we have structured our review into this table it's broken down by sections of the rule so for each section the key criteria are summarized in the second column the ongoing monitoring and reporting documents we collect are listed in the third column and our staff conclusions and any additional monitoring recommendations are listed in the fourth column. I'm going to go through these as efficiently as possible because there's a lot of information in here. So the first couple sections 201 to 2.3 concern the legal governing body leadership and management. The key criteria from the rule are boiled down there in that second column the third column again those are the documents that we collect and review each year. This year we didn't pick up we didn't find anything new so we continue to monitor these documents. There is an updated conflict of interest policy that will be reviewed in quarter four. Under solvency and financial risks 5.204 again I'm not going to go through each one of these documents I'll skip to the stock conclusions and additional monitoring. A couple things that we added there this year so so in the third column you see that we collect a financial audit annually quarterly financial statements we also review their finance committee charter. One thing that we've been discussing and you'll see in last year's materials is a legal and financial vulnerability assessment under this section. Some of that can be reviewed through the financial audit however these audits are not timely. We should be receiving an 19 audit this month so they're about a year it's about a year lag. So we are to help meet the requirement of the legal and financial vulnerability assessment. We are talking with one care about ways to get more timely documentation of risk analysis and assessment. We'll actually talk about that a little bit later when we talk about their budget material. So this is an overlap with the budget review. In addition to the Green Mountain Care Board Reviews Board of Manager meeting materials where some of these items are discussed. You can go to slide 10. In the provider network section again here are the documents that we review. We annually collect a network development strategy. This also overlaps with the budget recommendation. Something that you're going to hear about new in in the budget review this year is we are moving a lot of these well let me back up because we've been doing this now for several years we find that there's reporting that we want to collect year over year and instead of having all of those items you know necessarily spelled out in the budget order we're working towards to develop an ACO reporting manual that captures those items. So this is an example of one thing that will be in the ACO reporting manual the network development strategy. We'll continue to collect that. In addition another thing you're going to hear about in the budget is we are working on a curated provider network list with the Green Mountain Care Board Analytics team. This takes the provider list that OneCare submits to us year over year from 2018 up until now allows us to merge it into one file so that we can perform more analytics on that data and understand how the network is changing over time. So we're really excited about that project. You'll hear a little bit more about it but this falls under certification as well as budget and the recommendation here or the monitoring here is just to establish a relationship with OneCare analytics folks who can help our analytics team work on this list and answer questions. Under population health management and care coordination there are some policies that for review in quarter four we'll also continue to require more robust monitoring and evaluation plan for community specific population health investments. For example innovation fund and special team pilots again this shows up in that in the budget as well. You can go to slide 11 and again always tell me if I'm not talking to the right slide because my other screen still hasn't caught up. On slide 11 here we have performance evaluation and improvement section 5.207. Again we collected the same documentation that we have in the past quality improvement procedure and utilization management plan clinical priorities and quality improvement plan we'll continue to review and collect those. Under patient protections and support section 5.208 we collect semiannual complaint and grievance information and we review public comments submitted to the board and we collect feedback through the board's advisory committees as well as the things in the ongoing monitoring and reporting. We also I'll mention do keep in close contact with the office of the health care advocate who also collects you know inquiry or calls that come into their hotline on this issue. Slide 12 we're at the provider payment section 5.209. Again there's a whole slew of policies here that we collect and review these change over time and or or sometimes new ones are added. We collect those and and make sure we have the most up-to-date set of policies and there are several that are up for review in quarter 4. We can update the board on those as they come in. Under the health information technology section again a number of policies that we continue to review and monitor. We are also interested in gathering you know as these platforms and applications and the use of the systems have evolved we're interested in hearing from users and we may be interested in in repeating a demonstration of the these technology platforms as we did the first year that we reviewed certification in 2018. You can go to slide 13. This is some criteria. The first two which were added and don't show up specifically in the rule but they're in statute and so these are also criteria that have been included in certification since since the original certification was done and these were these were reviewed and again we continue to review them annually and there was they submitted updated information on these programs and we will continue to review that. Some of these items go into the reporting manual for example under the pay parity requirement. We have been looking closely at the comprehensive payment reform program that has been in place for several years now. The ACO reports to us twice a year on results in that program to help us understand how those payments are being made to independent primary care practices. I think you can go to slide 14. So slide 14 again this is a reviewing the items that one care will submit to help us to continue to monitor certification as we move forward. So one care is to submit any updated and relevant plans policies procedures agreements contracts subcommittee charters governing documents you know items that we monitor as as we go along in the year. These will come through the reporting manual quarterly semi-annually or annually as determined necessary in collaboration with one care. Financial statements are submitted quarterly. You'll hear a little bit more about the format that we want those submitted in. Executive team resumes we started collecting those I think last year so when there's an executive team change or somebody new comes on we collect those. Legal and financial vulnerability assessment again we're working with one care and how best to meet this need through audit or other financial reporting. Network development strategy comes in annually. Population health and care coordination evaluation plan comes in annually. Complaint and grievance reporting semi-annually and reporting on these areas of mental health access pay parity addressing childhood adversity reporting coming either annually or semi-annually. So the next steps for certification is to hear any board questions follow up or discussion on on the certification. Any public comment. I will note that the certification works process works a little bit different than the budget. It does not require a vote to continue certification. Like I said the ACL remains certified unless the board takes action otherwise. Mike you can correct me if I mistake any of this but what what we will do is publish a memo of these findings as we have in previous years. So if there are if there's certification questions or discussion they can come up in the meeting. Again we will collect public comment as well that the board can review and so with that I don't know. We didn't ask chairman if you wanted to do questions on this now or hold all questions to the end. Welcome all to the end. Okay great then that completes my overview of the certification section. You can go to slide 15 and I will transition us to the FY 21 budget review and oh my slide's caught up so that's great. Slide 16 is the next one. Okay so in approving an ACO's budget we're shifting now to the budget. In improving the ACO's budget the board will consider these criteria in the rule. So any benchmarks established under 5.402 of this rule the 16 criteria that are listed in 18 BSA 93 82 B1 that's budget specifically as well as any elements applicable to the all-payer model agreement. The board also must consider the public hearing which was held on October 28th with one care as well as comments received in writing from the public or verbally. We're going to view those in in just a minute and questions or comments by the health care advocates. And I also want to note that the full criteria are provided at the end of the slide deck as resource slides and you know by way of example some of the criteria includes working with to prevent duplication of services. How the ACO is integrating with the blueprint for health. Also how they are investing in primary care and community-based services. Addressing social determinants of health and adverse childhood experiences. The board also needs to consider how the ACO is supporting improved population health outcomes rewarding healthy lifestyle choices. So I'll make a note here that the criteria is quite broad and wide reaching. Giving giving that the board or sorry gives the board broad authority to oversee the budget while on the flip side the lack of specificity in the criteria of the levers that you have to bowl does present a challenge in homing in on the right conditions to ensure that the criteria are met. Which is why we have so many slides year over year to get there. In addition many of these criteria relate to the strategy underlying the all-payer model. As I mentioned which we'll discuss toward the end of the presentation as it relates to the administration's recent all-payer model implementation improvement plan. I'm going to pass it over briefly to my colleague Sarah who is going to say something about the public comment that we've received. Are you good to go Sarah. Can you hear me. Yes. Excellent. So this is Sarah Tewkesbury health policy analyst with the board. I just wanted to go over this slide briefly. Here we have a summary slide of all the public comments that the Green Mountain Care Board has received as a best survey which was December 8th. So far we've received 13 comments on the ACO's FY21 budget submission. And then in that left column you can see the list of organizations and individuals who have submitted their comments. In the column on the right-hand side of this slide you'll see a summary of some of the common themes that were generally seen throughout. And just to go over those there was a general increased appetite for transparency with the public and the regulators. Public comment also was from the public commentaries of the care navigation platforms data analytics and the support for the providers in the network. And there was a desire to see those things continue. Folks also commented on a desire for concentrating on expanding health care access for all Vermonters ensuring that that is something that continues to be at the forefront of both regulators and One Care's mind. Folks were overall they were pleased with the population health initiatives but would like to see an increase in funding to further these programs to see what else we can do to help Vermonters. General desires continuation of value-based care and then a lot of comments talked about considering COVID-19 and the global pandemic that we see ourselves in now. What does that destruction mean for the evaluation of the all-pair model and One Care's performance and how are we going to add to consideration as a group. So that was really the public comment and as mentioned before we are still obviously taking public comment until the 21st of December and you can find all of these 13 public comments we have received already on our website. So I'm going to have this made to Alayna start taking it through Roger Rapito. Okay so we we separated this into categories similar to last year. So we'll go through the ACO budget at a high level talk about the budget components provider network, payer programs and then what this means for all-pair model scale. Then we'll talk about population health in the model of care, One Care's risk model, administrative expenses, budgeted total cost of care and trend rates, quality and then regulatory integration. So to begin I think we tried we were thinking about how best to kind of roll forward and build on prior year. So there are a number of recommendations not all of them referenced here but you know many of the recommendations from prior year we expect to roll forward. One kind of new way of thinking about this is to think about what is really reporting and and to simplify the budget order and to allow us time to really be more precise in our language and expectations in in the reporting requirements is to move a lot of these items into our reporting manual and so we will work over the next couple weeks kind of propose what that sketch that out what that could look like but our first recommendation would be to you know simplify the budget order and ease administrative burden of operational efficiency and and move some of these standard reporting that can live in a in a more tangible document that lives year over year. In addition we have a couple new recommendations that we will talk about as we go go through this presentation. So the summary components I think year over year we have seen quite a bit of growth in 2018 it was around 634 million now in 2021 proposing a one point you know for almost five million billion dollar budget. It's similar to the original budget proposed in 2020 but as we all know there were some reductions there associated with COVID and and so we continue to see attributed live lives grow you know not at the rate that we had hoped or that are specified in the targets in all pair model contracts which we know are to be ambitious but there is still room to grow here. So just to make note why you may see differences here the 2018 and 2019 attributed lives are are based on actual lives including attrition whereas the 20 and 21 estimates are really about scale. So that is the January 1 attributed lives estimates and we see that as you know as I mentioned we continue to see this revenue growth you know the 20 budget is relatively flat relative to the 21 budget the 21 budgets relatively flat as compared to the initial 20 budget with a dip in the June 16 proposed revised budget by one pair. So you know I think the majority of revenues flowing through one care are you know I shouldn't say flowing through one care are they accountable for in this view of the budget about 96% is really for provider reimbursement that may or may not flow through one care and what does flow through one care is payer program support including blueprint funding state support participation fees in the in the hospital dues and then other grants and deferred revenue. So this is in some the dollars that one care is accountable for in addition to dollars required to operate these programs. On the expense side you know this we should see for each revenue an offsetting expense as they try to hit a zero dollar budget year over year in there they propose a zero dollar budget year over year in that income but we see kind of a similar around 95 96% goes to provider reimbursement whereas about one just over 1% for admin expense and population health is over 2%. So you know I think we need to think about these in two separate chunks in terms of the accountability dollars but then what does it take to operate one care and that's really the bottom two rows the one care admin expense in the population health or payment reform investments are also. So breaking down the components further I think we heard from board members and we'd like to see it in a per member per year amount so I think there we have to recognize in the bottom three line items that these are there are a lot of things happening here you know we have changes in population so I you know we have to be careful how we interpret these values but this is at a very crude level provider reimbursement admin in population health divided by scale over time so it shows direction and kind of another way of looking at relative investments over time or relative costs over time but we need to be wary about how we would use these metrics so we included it here as a reference point for your ease now turn it over into the provider network I believe as Sarah are you talking about this one yes I am so Sarah to explain again I worked on the provider network and payer program slides this year so I'm going to start here with this slide 26 this slide is here highlighted the changes to the one care provider network from 2020 to 2021 as you can see there were not major major changes to the network in the past year and in fact one cares network development strategy actually focuses on retainment and maintenance of the current network and how to better support the provider network rather than increasing the network so at the bottom you can see that the network expanded by Rutland Regional Medical Center and Community Health Center for the Rutland region joining the Medicare program and that there are four new entrants into the comprehensive payment reform program next slide please okay so slide 27 this slide highlights something really exciting that we're in Green Mountain Care Board Provider Network data that one care has reported to us since 2018 we're a little bit honest during the certification review but just to reiterate what's happening here one of our amazing data analytics teammates Lindsay Kil has been working to create a curated network list with all the data we've collected since 2018 this network list is definitely a work in progress but it's going to help the Green Mountain Care Board better understand the data we are receiving from One Care in a year over year capacity this is also a really great opportunity for One Care to and the Green Mountain Care Board to better streamline our data collection I mean I'm really excited about that because in the past the Green Mountain Care Board has not collected the same standardized data point since 2018 so we're going to work with One Care in the future and make sure that we back fill this data and verify it with One Care so that we're able to use it in a better way going forward next slide please okay so all this goes to say that our staff staff recommendations for the provider network will include an enhanced collaboration with One Care to better standardized templates for data collection and the recommendation is literally that crossing collaboration at the Green Mountain Care Board in partnership with One Care will produce a standardized template for data collection which will then be incorporated into the ACL reporting manual we also have a carryover recommendation from last year that has a minor change which is that we are asking One Care to supply us once again with their network development strategy and the minor change is that when we receive it this coming year it will be incorporated into the ACL reporting manual next slide please okay so now we've gone to the payer programs and this slide here is just a reminder and a disclaimer that the analyses for the payer programs done by the Green Mountain Care Board and the next couple of slides they are based solely off of One Care's submission since the payer contracts are still under negotiation so please take that into into consideration as we review the information on the next few slides okay so I'm on slide 30 for those of you on the phone and the purpose of this slide is to show the payer programs that are contracted with One Care and basically this table walks through the attributes of the payer programs so you can see going across the top we've got Medicare, Medicaid, the cross blue shield QHP, primary and then MVP it obviously walks through the quality measures that are aligned with all payer model payment mechanism risk and age of program please note that the blue cross blue shield QHP, primary and MVP risk columns are also contracted because that information is proprietary and we will not be discussing that you'll see in the new at the bottom for all that for all payer programs those services included in financial targets are aligned and this statement I've just made is based solely off of One Care Vermont's submission to the Green Mountain Care Board because these contracts are still in negotiation it's also worth noting attribution methodology Medicare's attribution is claims based while Medicaid is claims based and includes the expanded cohort Blue Cross Blue Shield QHP, primary and MVP's attribution methodologies are all proprietary on slide 31 okay and then this is a great transition slide as I'm about to hand it back the baton over to Michelle degree so that she can walk you through scale but this slide basically gives overview of how payer programs apply as a scale target initiative under the all payer model these following four requirements must be met in order for programs to qualify so that's sort of a transition right into hand it over to Michelle thank you thanks Sarah yeah so this is going to be just a pretty quick overview of what was discussed with you all at last week's board meeting but for folks who might not have been there I did want to provide a quick update so yeah the scale performance with One Care as our only ACO this is sort of where we're at currently and we can show here all the way through projected 2021 again that same disclaimer that I made last week that the estimates here for 2020 and 2021 are based on 2019 population and so those will change as an example of that and in light of full transparency we did notice a mistake that we had made on some of our federal reporting where we accidentally updated 2018 using the 2019 population estimates and so we have found back and corrected those errors but just to to make sure that folks are clear so the all payer scale to get for performance year one 2018 the final was a 22 percent and then for 2019 we have a 30 percent 2020 again still waiting for the 2020 population estimates but best guess right now is 42 percent and a projected 46 percent for 2021 the Medicare scale target again 35 percent 40 but 47 percent 44 percent and 56 percent for projected 2021 and again as I mentioned last week you know we are well aware that there is a scale target response as being put together between the agency human services and the remand care board at signatories on the model and we likely won't see the impact of some of these proposed changes until that performance year five time frame but so to keep that in mind as we you know we are making progress although not at the level that is required in the agreement as Elena stated but stay tuned you can move to the next slide Elena this is just another way to look at it I know folks like the the graph here so just another way to look and sort of see where we're we're missing so this is all pay your scale and if you move to the next slide Medicare scale again the population estimates will be updated as soon as we're able and I think that's actually it for me what I will add here is that as has been mentioned in several previous comments we will include again I think the requirement for the ACO to report their attribution numbers to us will be moved into that standard reporting manual so that's a recommendation that won't necessarily be called out as it follows over from previous years but will be moved into that broader reporting manual I believe with that I turn it over to Marissa Hi thanks Michelle so we're on slide 36 I'm going to transition over to the ACO population health and model of care section you can switch to slide 37 if you haven't already this graphic on slide 37 should be familiar to you all it depicts one care as model of care and core activities or programs within the model one care as care model is based on a four quadrant risk stratification algorithm that divides the population into healthy well early onset stable chronic conditions full onset chronic illness and rising risk and complex or high cost acute catastrophic the care model provides a framework for decision-making and resource allocation in the budget so that's why I present it here slide 38 please on this slide it's meant to boil down the seven criteria that are most applicable to review of the ACO's model of care and population health program so those criteria are cited there at the bottom in the left box you'll see that the criteria requires board members to review and consider these three buckets so there are incentives and resources and and that's the language right from the criteria you could also think of that as payment changes two is information that they provide or data and three is efforts or I think this is support or or tools that they provide and then on the right the criteria call out these priorities specifically and that is to strengthen primary care to integrate with community-based providers in the blueprint for health also specifically talks about mental health and substance use disorder as well as addressing social determinants of health and the impact of adverse childhood events and effects on appropriate utilization next slide 38 and again these these two slides 38 and 39 are to help you build a sort of a framework for thinking about and evaluating the population health budget so to on slide 39 here to review the care model and population health programs in the budget we looked at how one cares narrative testimony and reporting fits into this criteria so I'm going to call these bullet points here that you see you could think of them as core competencies of the care model these are bullet points as identified by one care in their narrative and I sort of put them under these buckets so in the payment changes bucket we have value-based payment design and distribution financial support through program investments under actionable data we have the four quadrant risk stratification model practice and hsa level population health analytics and evaluation of process outcomes and return on investment in the tools for care redesign bucket we have you know that one care the aco is meant to be a leader and facilitator of delivery system coordination as well as care management and care coordination support and they provide it applications for clinical care these include like care navigator the provider portals various applications for training and support of the provider network slide 40 please so on slide 40 these are noted changes and things to keep an eye on as we're looking at the at the budget so I'm going to go through some of these highlighted highlighted changes so the blueprint self-management contract which is in the primary prevention line item this is a contract that's transferring to one care starting january 2021 focuses on diabetes and hypertension management the change was a result of stakeholder engagement focus groups literature review and partnership with the health department and one care will use strategies to better identify the population that can benefit from these programs including wraparound support from rise vermont patient prioritization application in workbench one which is their data analytics platform and then there's a ramping up of the vermont health learn online platform particularly in light of the needs for online platforms during the pandemic complex care coordination so one care implemented a new schedule of payments in july of 2020 this was delayed from april due to covet again a lot of this you heard about when one care came in to present their revised budget and their discussion of how they had to revise these programs and investments in light of the public health emergency so i'm not going to go into that in in great detail so we asked one care for explanations for some of the changes or variances in these programs so under complex care coordination there's a notable decrease of 25 in funding toward this program and they describe this as refinements that are being made to the program in 2021 it is still an evolving program one care is working to focus efforts on high-risk subpopulations including you know those that have an impact on high ed utilization and inpatient remissions they're developing and refining graduation protocols to focus on who can benefit from this program they also talked about right sizing of the care team how to modify around covet when you can't have care conferences in person i also note in this bucket that they are you know working on increased engagement developing robust set of metrics there's there was discussion about increasing skills training for care coordinators and evaluating return on investment in this program longitudinal care program is the next item there one care discuss how they're expanding this program from burlington to six additional hsa's according to the narrative and testimony this program shows results in promise they state in their narrative a savings of over 1100 p.m. p.m. per member per month in reduction in inpatient admissions and ed utilization the longitudinal care program is also in the same sorry is in the same line item or bucket as complex care coordination this program is funded or currently funded through delivery system reform dollars and one care will provide plans for the 2021 program if funding is appropriate by the state and contracted with one care so that is still uncertain value-based incentive fund is my final item there and so this has been changed to have a more immediate distribution of funds throughout the performance year they're moving the quality accountability to settlement and tightening the set of measures to inform the bif incentive we will need to defer to final contracts here and we'll need more quantification on what this change means because you see there's a quite a dip in this line item so you're going to see that reflected in our recommendation and so you can flip to the next slide number 41 this is a detail of the expense line items for population health management and payment reform investments so I'll go through them briefly the top line on the top one there basic one care vermont pmp and this is growing with particular increased participation complex care coordination we talked about the dip there in the previous slide as well as the the change in vbif primary prevention this includes rise vermont program and the addition of the blueprint self-management programs so that's our understanding of the change there the specialist line item includes carry forward money for the well there the kind of kidney disease program was funded through this and then the mental health program as well and the the dip there one cares note is you know there's there's no new programing here the foundation and the focus again has been on primary care so there's not additional funding in this bucket in the 2021 budget innovation fund also no new initiatives but this fund does include you know several programs new americans clinic ocular telehealth and primary care telecare connections wellness plus community paramedic pilot dash mental health pilot again you know these programs as we need more information about it about them we should defer to explanations from one care the blueprint for health which includes in this table is the pc mh payments community health teams payments and sash added together i'm going to talk about that i think it's on the next slide but one more item here a primary care engagement is based on engagement with individuals who have not seen a primary care provider in the defined look back period so i think with that you can go to slide 42 which is sort of a summary of some of our analysis and takeaways here so the blueprint my bullet points down there the blueprint dollars have been level funded from 20 to 21 for historical purposes here there was about a 3 increase from 18 to 19 4.7 from 19 to 20 and this is based on an inflationary factor and so this is the budget and numbers here are different and they've been in the past also historically we have looked at population health management ratio so that's the population health investments to the revenue we've looked at this in two different ways excluding the blueprint dollars that's the second to last line there and that is because that is a defined bucket so it doesn't necessarily signify additional investments so we've looked at the revenue that way we've also looked at the total population health investments over revenue but either way you slice it we've you know seen over time that that ratio is decreasing we talked about this last year as well the the reason decreasing of course is a function that the total revenue is going to grow much faster based on new participation and attribution it's going to grow much faster than those population health programs can be scaled up appropriately so there's there's really no benchmark for the right ratio here we've seen how it's sort of played out over several years the programs don't scale up at the same rate as attribution so we have continued to use this as a metric though last year there was not a recommendation to hold it to a certain level and this year there's not a recommendation to hold that ratio to a certain level but we are we continue to kind of look and see where where it goes because theoretically if scale gets to a steady state then you know that could start to go up again but it's just something to keep an eye on as well I will actually let's see oh and another note about population health investments is that these funds are one way of sort of redistributing money in the system you know coming from hospital dues and then going out to providers or coming in from contracts going out to providers so you know that's why we of course want to see how that increases over time you can go to the next slide which is 43 this is just another cut of the population health investment over time just a little bit more visual the things that I'll sort of point out here is that the top bar the dark blue and sorry it's very small on my screen but that is the the you know the payment reform the pmpm so again those are growing as they should be that that section is getting bigger because as there's more participation then that's going to get larger the second one from the top the sort of lighter blue that's the blueprint and again that's held you know generally steady plus the inflationary factor which is not included in this year's budget and then the third box that you can sort of see there excuse me is the care coordination bucket which which does have some you know significant variants which we've talked about and one care talked about as well in their narrative and hearing and then the next one that you can sort of barely see the gray is the value-based incentive fund decrease from 19 to 20 which also one care talked about in their responses and their narrative explaining that so all of this is going to bring me to slide 44 which is where our recommendations are at this point so I will say that you know staff has some concerns over the growth of these investments over time we recognize that it's a balancing act you know the money has to come from somewhere so the hospital dues have you know we're decreased due to COVID trying to give some release to hospitals there and so it's a matter of both you know finding funding for these programs and having to balance out the needs of you know recognizing the difficult situation with hospitals and again this is sort of an area of overlap with hospital budget review also of course programs are evolving and so as they evolve they may take you know more admin to implement and or can't be you know can't be scaled up as we might like them to be because we want it to be not just throw money at something but have it be done well so I'll okay so to go back to the recommendations here again we've already talked about the top one there the shifting reporting requirements for ACL reporting manual again this is a thread that you're seeing throughout so some of the standard reporting is listed there the second bullet point if population health management programs are not fully funded as detailed in the 2021 budget submission one care must submit a revised proposal in the spring and this should include requests for budget revisions explanation of the changes any funding shortfalls changes in program scope analysis for each program line item talking about you know what can be scaled up by attribution or other factors this was in the budget order last year number three the our recommendation there is that one care must fund the Sasha blueprint for health in the 8.4 million plus an inflationary factor and just for by way of some background there going back to the original vote in 2016 where that included initial 7.5 million sorry initial 7.5 million dollars for this program in performance year one the vote justification you know does does specifically say that this was intended to be trended forward annually to fund Vermont's proven primary care and prevention programs including the blueprint for health and support and services at home and so this has been somewhat foundational to the the model at least from the board's perspective and finally there one care and again it should be a little tweak here because I do believe we do have the value basis into fund policy but we're also looking for one care to quantify the proportion of the VBIF that is now operationalized at settlement versus distributed throughout the performance year explaining and quantifying any and all mechanisms that tie financial incentives to quality performance so we just need to have a better get a better idea of the dollars that are tied to value because the line item that we have isn't quite descriptive enough of that as our understanding in the explanation from one care so that brings me to the end of the population health recommendations and the section and I believe I turn it over now to back to Elena to talk about the risk model yes okay um so the risk model thank you Marissa so just some background you know as a reminder one care Vermont assumes risk from the payers to provide care for or for the accountability of care for a particular population as specified in the payer contract the contracts with the payers do not specify how shared savings or losses earned under those contracts should be distributed rather one care designs and implements the methodology for establishing total cost of care targets for participating providers and any methods for distributing shared savings or losses these are documented in one care policy and I think we've had some of those policies to date that you know talk about the process through which they kind of finalize those distributions and I understand that because of the change in the risk model some of those policies are still under development namely the performance incentive pool so we'll look forward to receiving those updated policies and bring that on before the forward you know this is a snapshot of what the estimated risk distribution looks like this year um this is in thousands and there's approximately 19 million dollars at risk so this is off of the top of the total cost of care um and this is about 52 percent um held at the um by the network um UVM network um and I think the rest is um you can see kind of there's some variance in how it's um distributed and and um we'll talk about what that might mean later um so you know just to understand what the change is um I think we can go back to some basics so who is the primary holder of risk in the 19 or what we're calling the HSA model the hospitals were the primary holders of risk this is again um a design choice by the ACL in 2021 hospitals continue to be the primary holders of risk but risk is now expanded to primary care as well um the methodology for establishing total cost of care targets and distribution um under the HSA model is really based on HSA expected an actual performance particular payer program um in the 2021 model it's really about network expected um or an actual performance in a particular payer program still um with this 10 shared savings incentive pool if shared savings are achieved so you know we still need some details there to understand how that works um and then you know I think there is one thing that to consider here um is you know the HSA level model was very complex and often unclear um kind of the mechanics and and you know how what what can be expected um over time from the provider perspective and the network model does appear to be much simpler but I think we're still waiting on some information there to confirm that you know so in in some it this shifting from the HSA to the network model um proposes to increase collaborate collaboration across the network um hospitals may have more incentives to look outside of their HSA for a most efficient care setting there's increased motivation for the ACO to identify and lead strategic planning for system-wide cost control I think is a good thing um you know however it remains to be seen or you know or justified whether these incentives are strong enough for individual providers to motivate these collaborative behaviors um you know some some thoughts here is you know there's still attention between the placement into the most efficient care setting and kind of hospital incentives for revenue growth as they you know if they're still on a primarily fee-for-service basis so these marginal decisions may still come into play um the fewer lives an HSA has attributed the less richly they will be rewarded for their engagement um so that may not motivate behavior in the same way that some HSAs who have more lives may have um and then you know it's again it's not clear what the local performance incentive um is or how it works and if it's sufficient but um you know we look forward to those details and then there may be I think it's just important to note variation and efficacy of incentives um in either direction it's again unclear but whether or not a hospital owns primary care so um I think it's it's important to kind of note that we you know it may have been complicated before but we we don't really know or have a clear sense of um you know exactly what's happening here but also whether or not the there's a link between the incentives and kind of the desired outcome so we're looking for more information there um so while we agree that simplifying the risk model and evolving it to foster collaboration is a good one it's unclear from the budget submission at this stage how the risk model's underlying methodologies accomplish this objective um so we'd like to condition or we're recommending to condition the approval of one care's budget on the submission of some additional detail that allows us to understand the underlying risk model methodologies distribution including mechanics of the 10 percent performance pool um any market factor adjustments that may be applied um at distribution or prior to distribution and any other potential adjustments that are kind of on the table um that provider should be aware of before signing up for a program um and you know I think about if timing wise we can figure out what makes sense but I think it's the very least we need once we get the final contracts and attribution we should have this information before us um so if the information submitted by one care is deemed insufficient by the board we don't written is probably appropriate first step then I think we can invite them again to come discuss um the risk model before the board so we can really understand the logic behind some of the shifting incentive structures um okay so now fixed perspective payments um this is just kind of an update on prior year I think these are estimated and my apologies for not including the previous years um we'll try to update that in the next version this was kind of a last minute addition but you know I think we we are about 33.6 percent of one care's um accountable um payments or accountable lives are in a fixed perspective payment um this is about one percent increase over prior year um and this is measured as a percentage of total cost of care I think you know while this is an interesting statistic um and we can see how it varies across hospitals you can see that it's not really a huge percentage of provider income at this point you know it ranges from zero to you know 22 percent or 23 percent um so while you know they do have kind of a foot in the door it's really not we're not there yet right so I think you know we should think about whether or not it makes sense you know I think this was um another stream of discussion in HS's recent um all payer model um improvement plan but something that we've certainly been thinking about at the board is you know should we set our fixed perspective targets um what should they be as a state how do we think about setting targets for payers perhaps or um you know the ACO what should we think about would be a goal for provider budgets percentage of provider budget so you know this is the ACO budget process so I won't spend much time here but I think there is you know it's not just up to the ACO we have to have all parties engaged but I think it is something that we should continue talking about if we are serious about making the shift value based care and increasing fixed perspective payments for providers to really facilitate delivery system transformation um so with that we'll move into the administrative expenses okay so here's a snapshot of administrative expenses over time um you can kind of see um salaries and benefits continue to be kind of the major um component of one care's admin expenses software is relatively stable over the last couple years contract dropped um and then you know some of the other stuff we kind of occupancy and supplies are interestingly increasing despite um shifting to remote work but we did see risk protection kind of drop so that was I think um the product of um the method of protecting risk in the Medicare program um you know so salaries and benefits the there's an 18 percent increase over the 2020 revised budget it's about 1.5 million dollars so it's not insignificant part of this is due to compensation restoration due to COVID but we'll go into more detail on some of the drivers of those salaries and benefit increases um software like he says about flat contracting um did decrease they did look for savings for just essential contracts um in the other line item there is there was a note that the GMC billback would increase 100 160 000 but that is an overstatement I understand there really should be flat over prior year so that should come out of the budget and then occupancy and supply costs as I mentioned their lease expense um was proposed increased by 111 000 dollars um this spring um and then supplies continue to increase so you know I think this is just a little bit different of a trend than than we would have expected with the shift to remote working and um you know kind of trends we're seeing across the the state at least um so if we're going to talk about salaries and benefits um there we asked for some more information here to better understand it and I think you know this is a start but there's some questions still out there about how best to think about salaries and benefits and these kinds of human capital investments um however so start the net impact of vacancy reinstatements um it's about 500 000 dollars a reinstatement of leadership compensation that was a temporary um reduction during when COVID started you know COVID's still ongoing but another thing um was about 600 000 dollars and then there was a cost of living increase um for 209 000 dollars and then there's 170 000 dollars that um we didn't hear an explanation for but that amounts to about 1.5 million um dollars so as I mentioned you know what are the right benchmarks for these human capital investments how should we think about them um for an ACO kind of their impact on the broader health system what kind of return should we expect from this level investment so I don't think it's very clear it's very hard to find appropriate benchmarks um in this space and you know ACOs are still relatively new so there's not a huge amount of um comparative data but I think it's worth kind of pushing to think about how we can get some um deeper insights here you know I think One Care's organizational chart is very helpful um so starting place but it doesn't allow us to link um kind of their strategy to their human capital investments or their FTEs so I think you know the recommendation here um is for Greenmont Care Board staff to work with One Care to establish standard reporting of human capital investments as it relates to One Care's core competencies in overall strategy um and these could be you know I categorize a number of ways we could think about how FTEs are involved or support a particular population health or payment reform program what are the nature of these roles um and then who's you know supporting One Care's more kind of you know operations of leadership finance legal um so you know we're open to thinking about what this would look like to be most useful but I think that we could benefit from some more fine grain information here to link the budget to strategy more tightly. Retained earnings um so this is a new kind of topic for this year um so I think we kind of asked the question during their One Care's budget hearing about gap-based financials and and I'll kind of provide some background and more insight here um but in 2018-2019 this is a quote from One Care's recent response the Green Mountain Care Board budget orders required One Care to build and maintain reserves and as a result of this order One Care developed a budget that would increase hospital dues to supply cash that helps satisfy this budget requirement. Prior to closing out any fiscal year One Care engages with its governance bodies to evaluate the expected net income and consider options such as credits and dues paying providers um and you know deferrals in accordance with gap so you know we did ask for One Care to increase their reserves um you know and and well I think in 2019 it was about 3.9 million dollars um in 2020 we asked them to hold this reserve um and in 2021 I think we can talk about what makes sense here but some other information um that we just received last week um was you know kind of the accumulation of these reserves are actually over and above the requirements of the board set forth so in 2018 there was about a million dollars um of surplus so that got moved to net assets in 2019 it was about 4.7 million um in 2020 they're projecting zero net income um and so I think we need to talk about you know this puts us at a 5.6 or puts One Care with 5.6 million dollars of surplus as of December 31st 2019 um this would be more than sufficient to cover the 3.9 million that was required in their budget order in 2019 and leaves 1.7 million dollars of undefined surplus by the end of the year um in 2020 like I said you know this made sense because they were they were funding the risk for three network hospitals um in 2020 they continued to fund that risk mitigation but moved the risk mitigation to the founders um in 2021 the risk mitigation is contracted contracted to less than a million um but is expected to be held by One Care um you know last year we did allow them to maintain the reserve to allow for general liquidity um and I think that so makes sense but I think we we should be um we should have a conversation about what the right level of reserves are given that this is pulling money um out of the system and that we don't want this to just accumulate in perpetuity um so I think there needs to be some kind of conversation about what the right level um of reserves should be and and some transparency about why that makes sense um you know so I think there's kind of two kind of things to to note to keep in mind you know 2019 surplus was unaccounted for in the 2020 budget process we didn't have this information um we don't get gap-based budgets so the budget we get is an accountability-based budget so that's going to be something we'll talk about in a minute um but there's also uncertainty around the impact of 2020 that income which is currently projected at zero dollars so I think understanding of whether or not they really expect to come in at a surplus or a loss would be helpful um you know it's very rare that organizations tend to come in right on zero dollars and it's actually very hard to do um so you know if there is um a surplus or loss that should certainly be factored into the decision so the recommendation um as it relates to one care's retained earnings um is for one care to propose a plan for disbursement of undesignated reserves or to justify maintaining a particular amount of reserves um above the existing reserve requirement um I don't think this is something that we think we can come up with on our own but one care should help us understand what the right level of reserves are um for the system um without over-reserving and then one care should report the updated final 2020 net income and its subsequent use to the board at year end and then this leads us to the gap-based or submitting a budget that's in alignment with gap principles this would allow us to understand the cost of operating one care expectations for the coming year would allow us to understand the internal flow key performance indicators and operations at one care the levers that may be used by the board to adjust one care's budget um you know we're not going to affect health services directly but what what the board actually does affect is one care's admin budget and the dollars for which they are responsible um and then how do submitted actuals compared to audited financial statements this is something that we don't have a way of tying out um in its current state so um we've received the audited financials there's really no way to make sense of them as they relate to the budget for accountability is what we're terming the current way that we collect um one care's budgets and then as mentioned in the previous slides um the use of profits or losses at year end and and what happens to those whether they're applied to hospital dues reinvested in population health or they are maintained in a reserve for a number of reasons um you know that is something that um this would allow us to track and understand on a um more granular level so as you know as it relates to these gap-based submissions I think we can talk about the bright timeline is but we would want to um work with one care to crosswalk submitted actuals per budget submissions through the audited financial statements for the school year 2018 through 2021 and then beginning in 2022 as part of our aco budget guidance we would ask that one care submit its budget for accountability so the version we currently get um you know uh with a view that allows us to understand the aspects of that budget that aligns with us gap so we can talk about operationally whether this makes sense to do two separate budgets or whether there's a way we can submit one budget and make these kind of clear connections um in terms of the administrative expense ratio this is how we've thought about admin expense over time um is to look at relative to the total revenue um of the aco um which would include reimbursements for healthcare spending um if you look at um the admin ratio and the population health ratio just how we've thought about these kinds of trajectories of expenditures over time you'll see that the admin ratio is decreasing at a rate faster than the population health ratio and that's you know while we do want to see a deep reduction in the admin ratio over time the you know the relative rate is is a little bit troubling but I don't think we really have a great grasp on whether or not you know there are FTEs in the admin budget that really could be or should be categorized as um indirect support of particular program so I think that we can do some additional work there to provide some clarity but until we have that level of clarity it's really hard to interpret these ratios so just to kind of summarize some of the uncertainties related to the admin budget that we have to activate you know this relative rate um of reduction um in the population health and the admin ratio um is hard to interpret the number in nature of new positions at one care the amount of five hundred thousand dollars is unclear the unexplained salary variance um of 170 the overstatement of the GMCV billback and the amount of 160 increasing occupancy and supply costs despite the shift to remote work um and then believe DSR funding is uncertain um in general so that's another piece of note so in light of you know these uncertainties and the financial challenges facing Vermonters um you know and cost saving measures implored by businesses schools state and local government um you know we should really think about what the right level of administrative budget should be this year um and so we recommend um level funding the 2021 admin budget 2019 actual so this is about 15.4 million so approximately 700 thousand dollar um reduction compared to their um proposed budget which is 16.1 million um and then we would ask that this comes with a commensurate reduction to hospital dues or reallocation to population health and so you know I think a theme that comes forward is thinking about kind of what does this bias as we started a number years ago there was a budget order condition um that uh that requires over the duration of the all-term model agreement for one care's administrative expenses to be less than the healthcare savings including an estimate of cost avoidance the value of improved health and projected um to be generated through this model uh so we just wanted to provide a quick update um that you know our analytics team is working on this and they've kind of boiled it down to two um key projects so changing and provider outcomes so does one care change provider outcomes and then what is the return on investment of one care's population health investment so um I won't spend much time here because I think we could go into great detail but it might be something that we um you know our analytics team can kind of provide an update to us on um in the future on future date um and then just to mention and as Susan mentioned at the beginning you know there we have a number of um upcoming board meetings and one of them will be to discuss um the Medicare benchmark and I think as part of that discussion we can get more into budgeted trend rates and the total cost of care um but I just wanted to state that you know setting financial targets um during the pandemic is particularly challenging and while we don't anticipate any issues meeting the financial targets and the agreement it's something um that we'll look into you know when we discuss next week so you know I don't think there are any concerns here but there is a lot of uncertainty so um it is kind of hard to get clarity as the you know the situation is constantly evolving okay and I'll turn it over to Michelle um to talk about quality. Hi thanks Elena so uh just wrapping up on the requirements uh as it relates to one care and the agreement software model agreement um so here we just have a quick overview of the quality performance again um the the payers presented to the board back earlier in October on this uh information so Elena if you want to go to the next slide now we're on slide this would be 73 it's unmarked so I just wanted to um kind of provide again the crosswalk so the process that you're seeing here is specific to 2020 um again since we don't have final payer contracts for 2021 um I can't update this until that time um but just give you sort of a a heads up of where we are starting to see that that good overlap in measurement um all the bolded measures here which don't really look bold on the screen anymore um are ones that uh are the same across all payer contracts I will say that you'll note that the CAPS they're the consumer assessment of healthcare providers systems is theoretically across all payers however uh Medicare does release the final rule for 2020 performance and the CAPS requirement was removed and so we are currently working with our federal partners to see how that will impact all payer model reporting requirements and performance Elena if you want to go to the next slide so looking ahead the payer contract or the crosswalk as I just said will be updated to reflect 2021 when we have those contracts in hand um some reporting considerations again as I just noted 2020 um uh Medicare the CMS final rule removed the CAPS requirements in addition 2020 Medicare uh will likely revert to paper reporting only um and that is just due to their ability or inability at this time to do the quality measure validation audit that typically takes place at the federal level um I apologize for my dog in the background uh upcoming quality and reporting work uh we have again the ACO versus non-ACO provider analysis sort of looking at that um across the the state system um analysis on stayers and quality results over time so stayers being those who uh were attributed to the ACO in 2018 and continue to be attributed and looking at their health outcomes over time um or their quality results over time and then again and finally the ACO impact on all payer measures outside of payer contracts so um you know there are broader population health goals at play in the all payer model agreement and so looking and doing a deeper dive to see if um the ACO has an impact on any of those states as well and as I mentioned earlier I'll just state again that this will not be a formal recommendation from the staff but will be moved into that reporting manual that you heard more as I talk about um just making sure that we have uh updates and information from the ACO when it's available and that will go into that reporting manual. Elena you can go to the next slide and that's it for me. I think this is back in my court um so I think we're going to wrap up here but before we do um we're going to talk about regulatory integration with a particular emphasis on ACO oversight in the all payer model. Uh so just to I mean I think the theme has been mentioned a number of times but to be explicit um you know staff have been working on ways to identify opportunities to drive all payer model results through ACO oversight. Um one of the key pieces of work that we hoped to kind of evolve over the next year or so is to identify incorporate concepts of ACO core competencies and key performance indicators into the ACO oversight process um to start this work or to continue this work rather we um hope that one care per month um could submit their strategic plan um to the female and care board and this would be an important input to that work um as we consider kind of what the um the core competencies are that we should care about as a state um and then certainly another intersection is um HHS's recent um all payer model implementation improvement plan uh so staff analyze recommendations and identified intersects with ongoing and future work um and so that's what we're going to develop in the next couple of slides um you know and so we I just want to be clear you know some of these had um Green Mountain Care Board um as a responsible party and then some of them while we are not kind of the actor um in the activity I think that we can still learn and inform our processes from the outcomes of some of those activities as a part so number two reduce the Medicare risk corridor um you know I think this reduced risk corridor is reflected in the ACO's budget um proposed for 2021 um so that's hopeful and then number five recommendation number five from HHS ensure the Medicare benchmark provides as much stability and predictability as possible you'll hear more about that next week but I believe that that work is already underway and then number seven HHS and the agency of administration expect to conduct education and outreach and non-participating self-funded groups um we applaud these efforts um and the extent to that the ACO is involved in these efforts we would hope to learn about any outcomes in their scale strategy um you know we did ask them to present a one pager on the benefits of self-funded programs and they've submitted that last year um in um I think as it relates to more um kind of refining of um our reporting mechanisms um in the reporting manual there are two items number eight and nine um as it relates to kind of establishing clear milestones for fixed prospective payments um in contract model design and also understanding how the ACO um or how ACO participants um move incrementally towards value-based incentives the providers they employ so understanding how value-based incentives pull down um to the kind of point of care um and you know I think if we can understand the ACO's value-based payment strategy in more detail um you know in kind of in a cohesive fashion we can really kind of move the needle there um so how is the ACO working with payers and providers to increase value-based fixed payments across the system and then you know asking them to identify clear milestones and goals for contract design um with their in conjunction with payers um the next activity um annually in its budget presentation the Greenmount Care Board to the Greenmount Care Board One Care Vermont should identify cost growth drivers um across the network and how they expect to curb spending and improve quality so I think you know this aligns with many of the fundamental questions that are inherent in the reporting requirements that we already um have and the ACO budget guidance but I think there are certainly opportunities to refine and clarify those requirements um and I think the 2022 ACO budget guidance is a great opportunity to kind of move that to the next um next step um and then in conjunction with the ACO reporting manual that we hope to be more of a standard kind of mechanism for um reporting reporting templates and understanding what kind of data we hope to look at over time um recommendation or activity number 12 um you know partner with One Care Vermont to deliver system users um I'm sorry and delivery system users to evaluate the efficacy of care navigator I believe this is an HS activity um you know we would just hope to understand the outcomes of this coordinated effort um and we would also enjoy you know um receiving a demo of the tools that we can kind of understand on a more um experiential level kind of um to how this um how these tools are working and how we can kind of um understand their implementation on a broader level um relatedly there's another activity around um understanding the value of the data that One Care provides to its network participants um data and insights and so I think um you know similarly we would hope to understand um from One Care any efforts related to evaluations um and we would also you know um welcome a staff opportunity to kind of get our hands on the data and analytics and kind of experience what providers are experienced um and then I think this kind of echoes um a comment made by a board member Holmes on October 28th during One Care's budget hearing on kind of surveying uh you know and soliciting uh provider feedback um on the provider experience of tools and data and then finally um we understand that there is some work to be done to kind of understand roles and responsibilities between um HS One Care and community providers um and so I think you know to the extent that this unfolds it would be very helpful to our work and um to some of our you know some of the specific policies One Care's policies um to understand kind of where those conversations lead um as we kind of look forward to our future budget so we'll conclude with next steps um you know today we hope to have our bus board discussion of some of the recommendations that staff presented um and then here what else you may need from us or from One Care before you know next few weeks kind of unfold and you prepare to consider a vote on this budget um as we mentioned before public comment is accepted through December 21st um in order for staff to consider those public comments in their final round of recommendations um and then we'll conduct any follow-up if needed from today's discussion with a potential board vote scheduled on the 23rd at the same time as the Medicare benchmark um potential vote and I believe one date that's missing here is the presentation on the benchmark Medicare benchmark on the 16th that was mentioned by Susan earlier we also will post the Medicaid advisory rate case and the contract once it becomes publicly available as noted numerous times those are those contracts are still under negotiation and then you know at some point when this is all wrapped up we will produce the 2021 budget order update our monitoring plan finalize the reporting annual um and then you know I should say the last item but you know we should always remember that you know this isn't really final um at any point but certainly without final finalizing payer contracts and final attribution which is presented to the board in the spring have some resource slides there if you'd like but otherwise I will pause and Chair Mullen turn it back to you great thank you Elena thank you everyone for the presentation before I open it up to uh board questions to begin with I was wondering maybe if Robin might be able to give us a history of the support and services at home and blueprint funding and why it was a win-win for the state at the inception of this agreement and uh I think that there's different opinions of what this really is and Robin maybe you could help bring some historical perspective to it is that something you could do Robin sure I'll give it a shot thanks Kevin so when the the context at the time that we were negotiating the original all-pair model agreement was that medicare was sunsetting their medical home demonstration projects which was the source of the blueprint sash and community health team the blueprint pcmh and community health team and sash funding prior to the all-pair model so it was a priority in the negotiations to secure um some way to continue funding those programs moving forward in part because both the blueprint and sash had positive um federal evaluations which demonstrated medicare savings for participants in those programs so it made sense knowing that uh these were successful programs in terms of curbing total cost of care to want to try and maintain those um the mechanism that we were able to negotiate with the federal government was to include that in the all-pair model agreement and because that is an ACO based model the funding mechanism became part of the medicare benchmark conversation including with that appendix and to the agreement which allowed for um pre-funding if you will recognizing that uh those monthly payments that go out to providers that that those needed to continue upfront um so and as part of that we were able to negotiate that those that those program funding could be trended at the same level as the rest of the medicare program uh ACO program um and it's it's worth probably noting that prior to the agreement um those funds were not trended however they were paid on a pmpm basis so um so there's like pros and cons there in the current way that it's funded but the trend also kind of allows for additional growth in people participating in from medicare because otherwise it would be a flat amount more people as we reach scale which would reduce the pmpm um so that's that's really the context that we were looking at as we moved uh into the agreement and why that was an important component of the negotiation if there's anything else that or questions i'm happy to answer those thank you robin i think that was very helpful i'm going to open it up now for questions from the board and i guess i'll go and reverse alphabetical order today so starting with maureen thank you uh and thanks for your presentation it was a lot of material to go through and a lot of recommendations um i guess there's a few things that you know i'd like to talk about one is as far as the recommendations on page 69 i believe it was which was to level fund their admin costs um i'd like to talk about that a little bit and partially because i think the 15.4 million that you're talking about which is what will be achieved in 2020 to me is really a covid year their budget was 19.3 million their original budget in 20 was 19.3 million for admin costs and um the 15.4 obviously were achieving because they couldn't support a lot of the programs um and and they weren't hiring and they cut back salaries and things like that so it's not that i don't want them to reduce their spending um i just think to to put in a number that really was for a covid year when what their actual budget is for 21 is significantly lower than what they had requested for 20 for their 20 budget i'll just clarify there maureen i'm sorry if i misspoke the the level fund would be to 2019 levels right so the covid so that's 2019 was pre covid um so that was a 15.4 their covid budget is well below that 14.4 okay yeah yeah and their 21 their 20 budget that we had approved was 19.3 so that was the original budget we approved pre kind of uh them coming back and the reduced budget i think was really impacted because of covid so you're right you're we're level funding to 2019 but my concern is that you know we're in a growth mode now and we still only have a third of the population you know behind the aco um and so the costs for the admin and the population health both of those are are very small compared to the total expenses that we have because the bulk of the expenses are for um obviously for the payments from medicare may medicate and commercial and i think you all know i'm the one always pushing cost savings not you know not increases but you know i think here too where their board of managers really has you know a bit of an oversight over their spending you know when i look at kind of the discretionary areas there really are two it's kind of the admin costs and the population health and clearly we saw the population health numbers come down and i would like those to be higher um both of those the next dollar in if you will has to come from the hospitals for their participation fees and those are reduced quite a bit from what they had been you know in 2019 but that to me is also the the way that their board of managers works with many of them from the hospitals you know i think that is a good check and balance system there you know that they're challenging is this the right administrative structure and things like that and i just don't think it's the time to try to cut that back when you know a lot of their admin costs are the care coordinators and people helping support programs so i i understand totally you know that we want to look at things and have costs reduced and i think there's time and place for that but i'm not sure that right now uh the time is really to be pressured in there you know obviously that's one one board member's point of view so as as everyone else goes through i kind of like to hear hear where they are you know on that um you know looking at some of the other financial pieces um you know clearly they've they've changed some of the way they're looking at the risk model and how that will be administered this year um i i do think it's important to try to get the pieces of the risk out to you know all the people that are participating so not just the hospitals and having the providers in there as well so i think trying to move that way um you know could be a better way to look at it um you know i am also concerned that you know since they're now going to be looking at it more globally than rather at the hsa that some of the smaller participants they're not going to be able to move the needle one way or the other and so not to say they won't be working hard to to make this work but it's they're only you know five percent or you know under ten five percent of the risk reserve piece you know if they are if they if they're favorable it's not going to put too much into the pot and if they're unfavorable it's not going to drive the pot too much and so you just worry are the incentives you know to really get those costs to care down going to be there but again i think that's where some of the board of managers and the oversight can can look at that um you know similarly with the reserves you know we they built the reserves up over the past couple years they're not putting a reserve an additional reserve in this year i don't think they need to put an additional reserve you know when we look at how much risk is out there and with half of that lying with the network you know there's not a lot of additional risk there but as well if if there's additional use of that reserves it may be through population health which they need to come and get approval to to use those reserves or ultimately it may fund back again to the hospitals for their um participation fees so you know i think we're going to have to let's let's see what happens with the risk model and the reserves um you know when you talked about the gap reconciliation you know i think we should get the gap reconciliation um at some point i i you know i think we just need to get that branch for you know what are the reports that we have now and how does that look on the on the gap piece because um you know they should be able to do that but many times you do work with budgets that are not the gap budget that you know as we're looking at so i don't think that that's unusual and you know different things that come into play or when reserves are booked and you know a reserve may be booked in one year that comes back the next year and it really the intent of that reserve was the year before i think the cruel is i'm not talking the reserve piece so people understand but you know accruals that type of reserves um who changed that um you know i i just think that um we're just still so early in this process and that you know we need to get if we want to get this to succeed um you know i i do give the acl um some room to be putting forward what they think is the best things that are going to kind of going to work there so i i think what you guys have set up and you know the recommendations and the oversight um i think that will all be helpful for the process and really the only one that you know when i look to talk about changing would be the level funding you know really for what you know i've described and i just think we need to be really clear about you know what again what the this year's budget and how much that we've grown from 1919 2019 to 21 right so the the dollars have grown a lot the participants have grown and to cut that back at this point you know that that may be a challenge um so that's all i have thanks so i would just follow up on that marina that i viewed it differently than um level funding because if they're at 14.4 million you're giving them the ability to go to 15.4 million you're talking about a seven percent increase and i i get very much that the 14.4 is cut from um where it was in the budget because of what happened with covid but i would also worry about a rapid growth spurt in uh admin dollars and so i i looked at that a little bit differently than than you did and you may be right and i look forward to it right it's 19.3 that they had originally budgeted and i think we need to understand at least how much of the reduction to the 14.4 um were because because of covid where they couldn't really reach out and run some of the programs that that need need to be run because they because you needed to be in person and things like that so you know that that's where i would question that but the the other question i have for you marine is you commented about um not having any um money's going to reserves i i'm not so sure that i would be calling it going to reserves but retained earnings and it almost looked like there was 1.7 million and if they've already built up uh enough dollars to um really meet the goals of what we originally hope for to mitigate risk i'm curious if you had mentioned that it might be for population health measures well if it's for population health measures why didn't they just budget those population health measures as part of their expenses yeah i didn't have any question for them yeah okay tom thank you can uh can you hear me because i you guys have been breaking up a little bit over here but so am i coming coming through to you you're coming through loud and clear and uh all right nobody was here i'm gonna leave my video off just to kind of keep the strain on the system as as little as possible um my first i i only i have three or four areas that i just more want to emphasize than discuss um the first has to do with um slide 52 which is a slide that profiles the percentage of fixed prospective payments and across the system uh it's uh it shows that total it's 14 and a half percent um of hospital budgets and i just um i i feel a little bit like we're flying without a clear target in mind in the future um we're four years into the all pair model and i can't tell you um where we should be um ffp as a per percent of say revenues or expenditures of the hospitals um the whole concept is to have a mild capitation program which is fixed prospective payments and to use that to encourage efficiencies and uh um and savings and investments and population health etc but um as i look back at the 2019 numbers hospital fpp was a 10.2 percent in the 2020 budget it was 14.5 percent and now it looks like it's projected again for 2021 at 14.5 percent and so i i would like to maybe ask the aco tell us where we need to be in order to get the kinds of leveraging and efficiencies that are are anticipated as part of one of the fundamental structures of the all pair model which is transitioning from fee for service to fixed prospective payments is it so for the major providers hospitals which are 50 percent of the the spend pie is it 30 percent is it 45 percent you know where where what is the number that we should have as a guiding star that when we go through budget review for hospitals and we go rate review for the insurance companies that we are trying to manage toward that target that we are explicitly aware of a target um we understand what its underpinning is um and and work toward it so um i i i would be supportive of a provision to ask the aco to recommend us not to establish it but you know to have a conversation with us a formal conversation with us as to what that that target should be um also consistent with that i just wonder what is the capacity of the aco should fixed prospect payments become a bigger piece of of their activity um you know if if the target is um 30 percent or whatever the target is is the aco um i mean we we've done a good job i think of getting the aco up and running it now um functions and it has a couple of years under its belt it's still new but what is where would it need to be in order to be able to reasonably and economically and efficiently manage you know a doubling of of fpp or could they do it with existing resources so that's that's um one of the areas the uh the next one would be having to do with the model for care and the top two quadrants in that um chart that is presented i think on page 37 but it's one we've all seen many times um which uh you know talk about uh or profiles 84 percent of remoders as being a in a low or medium risk quadrant and i'm just um would like here again to have the aco recommend to to to look to look at at their um metric for population health and uh communicate with diva um as to re um evaluating the benchmark plan it just seems to me that um you know that the qhp population is a large portion of the aco's um coverage uh 70 or 80 thousand remoders and that benchmark plan under plant underscores their relationship but i don't believe um it is well aligned with the population health metrics that we're trying to achieve and so um i think it would be valuable for the aco and the people that that they represent and for the board but to have a conversation with diva about reopening that benchmark plan and restructuring it so it's better aligned with population health going into 2022 obviously the 2021 period is is is just too close in hand but to start the process going so that um this time next year you know we can all be certain that the benchmark plan is is well aligned with the health care reforms that we're trying to achieve my third area would be um uh related to slide 56 um and on that slide what is profiled is of the of the amount of risk um in play how that is distributed over um the different hospitals and for example uh uvm uh is looking at 34.8 of it um and as another um kind of point uh northwestern is 8.6 of it but uh then when you look at that amount of risk relative to the revenues of each of those hospitals it's less than one half of one percent for uvm medical center and it's 1.5 percent basically for um northwestern so i'm just you know i i'm just i i i the risk is relative to their revenues what kind of revenues are they putting at risk um in their risk corridor and i i think looking at it in terms of a percentage of the revenues is helpful um and informative and i um can um uh kind of expose and have as part of the discussion you know the impacts of the payer mix and the cost shift uvm medical center is much more able to uh cover to um cover their risk than i think northwestern is just given the payer mix and cost shift but that's kind of buried in in in this system so um that that's a concern of mine um and the fourth area is in terms of of rearranging the risk i'm not going to spend the kind of you know approach to risk i'm not going to spend a lot of time on it but i worry that moving to a system-wide uh um approach with a 10 percent um kind of kicker there for areas that might be doing well is is something and i know the staff has asked for this so i'm just emphasizing something they've asked for is is we need to better understand that why is 10 percent the number a um what happens if um the uvm medical network sneezes in that system do all the other hospitals you know then get a cold because because the medical center is more than 60 percent of all revenues across the 14 hospitals in vermont so i understand maybe the need to kind of find some consolidations and efficiencies um and how risk gets allocated but i worry that that we go to a system where the good efforts uh independent efforts of southern vermont or northeastern or north country hospitals kind of get lost in the fray and they live or breathe with how the network hospitals are doing in terms of um savings and um and shared savings and and earnings so i guess i'm just reinforcing what the staff is saying we don't know enough there i i i don't know where the 10 number comes from i i don't know what it means and i'd also would like to hear from the hospitals about what they would think about that um uh you know is whether they would rather you know pull their fate with uvm network or um remain relatively independent other than that uh those are the areas i think the staff did a great job of laying out all the issues it's incredibly complex and uh i know from talking to you you know there's probably done some hair pooling from time to time but i i really appreciate your effort and uh and uh the conversation that we're having and i think we'll end up in a good place thank you tom thanks tom um robin thank you um i'd like um i'm glad you guys are uh put in the recommendation for uh having the team get a demo of the tools i think that uh when we did that the first year that was really helpful for staff and a lot of our staff on on this team is turned over so most of you haven't had that opportunity um and i think having you have that experience will kind of bring it to light which will be helpful so i do like that um part of the uh certification recommendations um to morrin's point i am concerned about the decline in the population health management spending um i i do think it makes sense to ensure that we're targeting the care coordination program appropriately so that um we are efficiently using those dollars so uh maybe and certainly the areas that um marissa mentioned around ed utilization and uh i believe it was readmissions makes sense i don't feel like i got a very good complete sense of how the what those sub populations are other than those two that marissa mentioned um so i think i could be made more comfortable if i had a more granular sense of that um so if that's something that the aco wants to provide that would be helpful to me um on um on slide 30 obviously we can't because of the confidential proprietary information it's difficult to talk about the risk components in the private in the commercial payers um i when i went back through my materials um i did have a couple of questions about that and so i'm wondering if we are and this i guess is really more for you kevin i'm wondering if we're thinking about potentially having the aco come back in um sometime in the next couple weeks before we vote to to kind of address some of the issues that we're raising and if so that might be an area that i would be interested in exploring and a little more granularity with them which probably requires and not probably it would require an executive session so i'll just put that out there i would leave it to them whether or not they wanted to answer um this presentation and writing or if they wanted to um have a you know a virtual meeting and um at that point robin i think you'd have to be prepared to go into executive session yeah so um that yeah but it's a little bit hard to talk about now because i can't really pose my questions without us going into executive sessions so maybe i can just pass that on to staff okay um the questions just so that the public has an understanding that relate to um ensuring that we are strengthening alignment across the payer programs around uh the items that are outlined on slide 30 particularly around risk um in terms of that admin budget uh i think moraine you made some good points around we want to make sure that as we're growing attribution that we're not underfunding some of the supports that we feel like are needed um at the acl level and um to that point i liked the part of the recommendation that tries to work through how do we take the admin budget and understand how much of it is really uh population health support so in the last i don't remember which meeting it was but i mentioned how the blueprint has these different components including one which is essentially technical support to the provider level and i think some of the admin personnel at the aco may function in that level in that way um and i think there is an analogy one could make to the medical loss ratio calculation that's used with insurance companies which carves out um care management resources from the admin percentage so i think trying to figure that out would give us a better sense when we're looking at the admin budget what's supporting uh the programmatic components versus uh what i would personally consider as true admin um i guess i want to hear more from um if the aco chooses about their admin budget justifying the increase because it's hard for me based on what we have to sort out how much of that increase supports the core programming versus um other stuff um so i haven't really i guess made up my mind on that yet because i hear both sides of it um and i do think you know we have identified 160 000 in terms of the the billback which was uh not accurate so we know of the 700 000 the staff recommended cutting 160 at least is immediate right there but um obviously we're not going to get into that level of line item cutting we don't do that i would leave that to them but having a better sense of that would be helpful at least for me in making up my mind um and um as i said at at the budget hearing um i am in favor of trending for the blueprint dollars i think especially when you're looking at attribution and an increase of about 9 000 medicare uh attributies that if you level fund you're really doing a cut to the pc mh program which would be um funded the same amount but delivering services to 9 000 more people um i think those were my comments great thank you very much robin jess great um well thank you and thank you to the staff i know how many hours we put in on this very very thorough review appreciate it greatly um i guess i'm going to echo some comments i've already heard so i'll try and be a little bit briefer um the beauty of going second to the last um so around i you know it is discouraging to see some of the reduction in care management dollars population health investments in particular care management dollars and i just want to note that some of the budget amounts rely on yet to be determined funding from dsr and so to me it's also going to be important to understand um some of those care management you know funds may actually be less than even in the budget if dsr funding doesn't come all the way through so what are the consequences for delivery reform um and total cost of care effects that might happen if this if these dollars don't come through but also uh is there a commensurate reduction in administrative costs if those programs um are not able to be funded so you know how do we link each of those programs to the support that may be required to administer them if the funding doesn't come through so hopefully it does but um i'm just recognizing that some of this funding hasn't been actually allocated yet uh i share tom's concerned around the discouraging you know sort of the look at the the proportion of payments that are fixed payments um obviously delivery system reform is not going to happen until we have payment model changes so it would be helpful to to hear from the aco uh maybe this is a recommendation that we add i can't remember all these recommendations but what is the strategy to be getting that is a recommendation in there but i think it's really important one what is the strategy and what are the milestones that we can expect to see to get more uh payment in fixed perfect fixed perspective payment i think it's just really important to be thinking about that um i also share others concerns around the risk model um i do agree i like the idea that the risk is going to be spread beyond just the hospitals i think that's important to other providers but i'm not convinced yet that this model necessarily incents the shift to the most efficient care setting particularly given the fact that there's such a low proportion of dollars in fixed perspective payment so actually i would think that providers would have greater incentive to shift care to more efficient settings if their risk is tied to their local performance not necessarily the total networks performance i worry about a free rider problem particularly you know if there's an hsa that has low attribution how much is that going to incent behavioral change delivery system reform so i think i would need more information from the aco understanding how this risk model works maybe i'm just not fully understanding the justification for how it's going to better incent delivery system changes that we want to see how are we going to know it's working the model suggests that there'll be more collaboration will there be a measurement of that do we mean how are we going to know if this new risk model works better than the old one what's the measure of that so those are kind of some big bucket thoughts i think for the most part the recommendations i agree with the admin costs i'm listening to robin i'm listening to maureen i think that's going to be a ongoing conversation that we all have to think about i do think at the end of the day we probably just don't have enough information right now you know there was it sounds like there was an overstatement of billback it sounds like there are some it's unclear what some of the salary increases are for new growth there if their population health supports if the care management that's one thing if they're for other administrative overhead maybe that's a different story i think just more information may be helpful understanding the growth in admin particularly when we're seeing population health programs and investments declining it's just an important understanding there and i i guess i would say to to maureen point i think the yes there was a reduction in admin overhead because of covet we're still in covet and actually covet is actually worse probably now than it was maybe back in june when they adjusted downward so for me it would also be helpful to understand what's the covet impact on the programming that's anticipated you know that relates to admin if the reduction was because of covet it seems to me where covet is not much better now it's in fact worse so how does that all you know come together and just a last question and this is probably just a small clarifying question but the cpr funding on slide 41 went from 1.3 million down to 1.2 million but on slide 26 it was talking about four practices added to cpr so i i'd have to go back to my notes and remember how that all works but if somebody has a quick answer to that how the total funding for cpr could fall despite the fact that four practices were added yes you're looking on slide 41 the comprehensive payment reform line item from 20 to 21 it goes up from 1.1 well it's it's not a reduction it's a slight increase what was it in 2019 i guess now i don't have it up in front of me now can you just go to it from 2019 1.3 okay and now it's 1.2 oh i see i see from there yeah so if we're left in 2019 to 2021 i guess i'm just and maybe it's because there was a drop in 2020 of number of practices and they bumped back up and on so i guess help me understand that you can do it offline but i think they paid out less than they expected um from from in uh 20 um but that can be okay but yeah we can get some more clarity it wouldn't be covid because of the fixed payments i guess i'm you know i when you would you would think that if you're adding four practices you would see a growth in um that line item at least i would that was my thought there so it's just yeah from pre-covid i understand yeah but that's it for me i appreciate all the hard work though thank you so i guess for me you know pretty much everything has been said but i'm still struggling with the fact that we're this many years in and we still don't have a handle on things as it's reported you know when you have a discussion about uh holding admin costs flat that's really about true admin costs i'm not so sure that in my mind um a discussion on population health or community care initiative should really be um put in the same area as admin costs and and for me i'm talking about holding the administrative costs of the organization itself in check not trying to put in place a check on um anything that would have benefits but then once you get to that statement about anything that would have benefits i mean i go back to what i said i think a couple of years ago when i was referring to the um project that rrmc did with reducing readmissions by changing the way the cardio practices were conducting business and you could target what your savings were and yet here we are in 2020 and we still can't say that um this population health initiative saved x amount of dollars because because this program was put in place and and that's what's kind of troubling to me that you know we we've worked towards a dashboard but i still worry that we're not getting the feedback quick enough on where the successes are and where the successes are maybe where you really need to put that additional money in that was talked about um because if it's working well in one area it might be able to be replicated and work well in another area of the state so i just uh it's more frustration than anything else and that frustration carries forward to not being able to explain certain things like i've heard today we've we we believe that the 160 000 in the budget for additional billback was in there inadvertently but i still don't know that for a fact um we don't know if they just misbudgeted last year and that's from that i assume that since we haven't heard anything from them that that was not the case but every time i make an assumption i really worry about that um and i still get back to um when you're talking about this type of an organization if you don't have the purpose of days cash on hand or reserves for specific risk mitigation why isn't that money just allocated an expense line for population health initiatives that would be able to demonstrate returns in quality access and cost containment and so i i guess i'm just frustrated with the whole process because it doesn't seem to get to where i hoped it would be um um you know just two years ago even so um and i feel like there's a disconnect on the benefits of the sash and blueprint programs i know that when we've done site visits it seems to really make a difference and i get that really uh by putting it into the aco it's affecting more than just those areas that are participating in the aco so i get that side of the argument but i'm not sure if i get any other part of the argument and so that's something i'm still trying to dig to the bottom of um to fully understand because it seems like if you can prove that these are winning programs and certainly all the analysis that we've seen to date have shown that they're winning programs and that's what we should be endorsing is winning programs whether it's you know programs that you know keep people from moving to from pre diabetes to full blown diabetes or or whether it's a program attacking hypertension or you name it we've got to be able to have some type of measurement of what they're bringing to the system so that that's just uh me venting that i still don't think we're where we need to be and with that i'll open it up to public comment does any member of the public wish to comment well i'm not seeing any hands raised and i'm not hearing anyone okay so i think the next step really is for staff to reach out to the aco um see if they wish to provide written answers or have a virtual meeting and really advise them that if we hit that we may have to go into executive session in that virtual meeting and prepare them for the questions that board members have raised today and uh why there might be that need for that uh executive session does any board member see it differently hopefully i'm just not uh having any uh volume on my uh computer this is susan i checked my phones to see if anyone couldn't get through sometimes people text if they have issues so i don't i don't see any activity there yeah i haven't received any texts either and i don't see anything in the uh chat function so i'm going to assume that um nobody has anything to bring up at this point but they're certainly welcome because we have that open public comment period through the 21st and we certainly have more answers that we need to seek out from one care before we're prepared to make any decisions so with that i just want to thank the staff um there's a lot to digest and i know you have been working feverishly trying to digest it and it just doesn't seem like it's still going through the digestive track well but we'll get there and um with that is there any old business to come before the board hearing none is there any new business to come before the board hearing none is there a motion to adjourn no moved it's been moved and seconded to adjourn all those in favor signify by saying aye aye opposed signify by saying nay thank you everyone have a great rest of the day