 Okay it looks like everyone's here so I'll call to order the Green Mountain Care Board's hearing of June 14th 2023 with everyone's well. We have two ACO oriented agenda items today. The first is the one care revised fiscal year 23 budget and a potential vote is noticed. And the second is the Medicare only budget guidance presentation. But first we'll turn to our executive director Ms. Barrett for the executive director's report. Thank you Mr. Chair. I first want to thank Lamoille County for our visit last week. We had a really wonderful day in that community learning a lot about the health care entities and their landscape as well as some of the remarkable businesses in that county. So stay tuned the board's going to get out on the road again likely early fall and we'll be organizing that over the summer and keep you in the public informed as well as the board. I also wanted to mention a couple of public comment periods. As Chair Foster noted we'll be discussing a Medicare only ACO guidance today and Julia Bowles will be presenting on that and we'll share more information on the ways you can public comment on that guidance. And then we also have the ongoing public comment period on a potential next model with the centers for Medicare and Medicaid innovation. Please send any of your comments to us. We can share those with the agency of human services as they are leading those negotiations. And with that I will turn it back to you Mr. Chair. Thank you and yeah we did have a really wonderful meeting in Lamoille. I want to thank everyone for having us. The participants were really well prepared and had a lot of thoughts. I enjoyed hearing a lot about how some of them were working together to solve some of the problems and to find some savings and efficiencies. There's a great panel and thanks Julia, Susan, Kristen and Dave for doing all the prep work to make it go so well. It was great. And with that I'll turn to the meeting minutes from that meeting which was June 7th. Is there a motion to approve the minutes? I'll move approval. I'll second. All those in favor? Aye. Aye. Aye. Aye. And the minutes are unanimously approved. Thank you. And with that I'll turn it to Michelle Sawyer and Russ McCracken for the one-care revised fiscal year 23 budget. Michelle, how are you? I'm well. Thank you, Chair Foster. All right. Let me just get my screen all set. All right. Thank you all for being here. I'm Michelle Sawyer, Health Policy Project Director with the Green Mountain Care Board. I am joined today by Russ McCracken, staff attorney. We are here today to consider a budget amendment request made by one care Vermont. So the agenda today, first we will discuss the timeline for 2023 budget process. The public comment received around the revised budget. We will summarize the staff analysis of the revised budget and how it varied from the initial budget. We will touch on the budget amendment request and then we will move to the staff recommendation. So I wanted to take the timeline, the time to highlight the timeline and the steps that have been taken by staff, by the board, by one care throughout this budget process for fiscal year 2023. So this started back in October when one care submitted their budget for 2023 to the board and presented on it during their hearing in early November. And at that time one care had anticipated a continued payer program for 2023 with Blue Cross Blue Shield in Vermont. And it wasn't until late December, just before the vote that it was announced that Blue Cross Blue Shield would not be participating with one care for 2023. There were a number of notable budget order conditions included with the approval of their initial budget that included a cut to their administrative budget and to one care holding $3.9 million of the Medicare advanced shared savings dollars at the entity level as risk. The board also responded by ordering one care to resubmit a budget in late January that better reflected the reality of the situation with the loss of Blue Cross Blue Shield's contract. The letter from the chair that was sent on February 9th also signaled that the loss of primary care and population health management dollars flowing to the network was of utmost concern. All in all the changes between the initial budget submitted in October and the revised budget in March are substantial. Some changes are due to the loss of Blue Cross Blue Shield. Some are due to one care's response to that loss. And many of the changes have to do with the direction provided by the board through the February 9th letter and the budget orders. So we received seven comments in all from five different parties. So the topics covered were executive compensation, primary care funds flow, sources for one care's administrative costs, a reduction in one care's operating budget, and there was a comment about triggering events. All right. As previously mentioned there have been many changes made to this 2023 budget but the substantial variations from the approved budget and the revised budget can be summarized in these four bullet points. So the loss of the Blue Cross Blue Shield Vermont contract. There is a new self-funded program for fiscal year 2023. There was a change in the risk model through the addition of this payer program and the risk corridors for the existing payer programs. And there were changes to the population health management model. Because the revised budget that one care had been operating under during 2023 varied substantially from the approved budget, the Green Mountain Care Board requested that one care submit a budget amendment request. This request is the basis for the vote today. However, additional information came to light during one care's revised budget hearing regarding the nature of primary care funds flowing through hospitals. Concerns were raised by the HCA and other public comments. We are reviewing some of this information today. So this slide shows I would like to direct folks to look at the top line item, the hospital slash hospital PCP. Now, the green column is what one care had submitted in their original budget last fall. These are incentive dollars. These are FPP are not included in these dollars. These are funds earned by primary care hospital owned primary care. So you can see the number is 10.2, 10.3 million dollars in the original budget. When they came back to us with a revised budget that changed somewhat. So the amount that one care was going to put towards these funds dropped to 8.6, 8.7 million. However, there are additional monies going to primary care, the hospital primary care through diva payments. They are paying outside of the one care flow of funds, blue cross, blue shield in response to no longer contracting with one care about their own payments made to primary to support primary care. So that's going to those folks. So the total overall flowing to primary care for 2023 is approximately 10.55 million. But it's one care 8.667 million of us coming from one care. So these are the dollars that were of concern that came up during their hearing. One asked, you know, what happens to those funds once the hospital is paid for them? One care was unable to explain or verify that those funds do flow back down to the providers or at least the practices that earned those funds. So one care pays out at the tin level, which means for hospital owned primary care practices, the hospitals are paid those incentive payments. So like I said, there have been concerns about those dollars meant to strengthen primary care, perhaps not making it to their intended place. So to ensure that the funds approved in the one care budget to strengthen primary care are reaching the intended purpose, the staff has suggested the following approach. First, we would require one care to collect an affidavit or attestation from hospitals in the one care network that that receive these PCP funds, that those funds go to primary care providers and primary care transformation as additional payments. We put a compliance deadline, just a starting point as October 1st, that is when they are required to submit their fiscal year 24 budget to the board, but that's up for discussion. The second step would be to include a similar requirement for next year and beyond. Currently in the draft of the fiscal year 24 guidance, there is such instruction, which we will, the staff will present this guidance next week. And then thirdly, we would like to also get around kind of the other side of this and collect from the hospitals really their accounting records, so that we can see how the money enters their system and how it flows through and is supporting primary care. And there's a couple of options regarding how to go about that, exploring that. We could require that one care collect this information from hospitals and report back to the board. Alternatively, the board could explore doing this possibly through the hospital budget process, asking hospitals directly to provide that to the board. So this is what the staff is recommending and at this point, I will hand it over to Russ to walk us through some suggested motion language and then we'll have time for discussion. Thanks, Michelle. As Michelle said at the outset, this is a review deliberation and potential vote on the amendment request that One Care provided that asks the board to update its approval of One Care's FY23 budget to be consistent with how One Care is operating, which was reflected in their March 31 submission. So to that end, we had a staff recommended motion language here just to approve that amendment, but include with that a condition that One Care obtains the affidavits or attestations from its applicable hospital network as Michelle outlined on the prior slide. Thanks, Russ. And I will turn it back to you, Mr. Chair, for discussion. Thank you, Ms. Sawyer, very much. Two quick questions, and I'll turn it over to the other board members after, but I recall there was a question about whether or not those funds were reaching their intended destination and use, and you said they were unable to verify it. Do we have an answer to that as of today? We haven't received an update. The additional information that we have collected since then is we did receive from One Care the documentation that they include along with those payments. So when they send the payments to the hospital, it does outline which practices earned how much and for what purpose they earned them. So the hospital is in when they receive those funds, we can say the person looking at that is able to determine how much should go to each practice or how much was at least earned by each practice. What has the ACO done in accounting to inform us as to whether or not historically some of those payments weren't being actually used for that purpose or were we still uncertain? We are still uncertain. If they have done so, they have not communicated it to us. Okay, thanks. I'll open up to board members, questions and comments. Can start with Member Walsh. Thank you, Chair, and thank you, Michelle and Russ. I want to start with some comments and trust that we'll move on to some discussion. I realize that today we're here to discuss the amended budget. The amended budget, the budget we passed in December reduced One Care's budget by 2%. That was prior to any accounting of Blue Cross Blue Shield or any of the new information that's come to light since we passed that budget. The revised budget that was submitted by One Care was reduced by 2.6%, meaning 0.6% reduced on top of what we had originally ordered. That's the backdrop for the meeting, but I think context is important. We've been talking about what has been an underperforming ACO. We've had trouble early with attribution and scale shortfalls, but no improvement for access for Vermonters, flat or deteriorating performance and benchmark data, Medicare, Medicaid scorecards. We've talked about Blue Cross Blue Shield withdrawal. In addition to that, what's also happening since we passed the budget is the unwinding of pandemic era Medicaid expansion. So the number of covered lives with Medicaid will be reducing this year and over the next several. In addition, we've learned that One Care is spinning off two of its three core functions. There's an analytic function moving to the UVM network. Here we see persisting anti-trust concerns, but more importantly from a revised budget perspective, there's a lack of clarity regarding the scope of the analyses to be performed. They're spinning off their population health and quality improvement function, also going to UVM's now Population Health Service Organization. And again, from a budget perspective, there's a lack of clarity regarding the scope of work that's going to be performed. And then their third core function, the one that really can't be done by any other organization, is the financial pass-through function. Those dollars passing through are meant to ease primary care practices transition from fee-for-service to alternative payment models and reward providers for good work. However, what we've discussed already is that roughly 57% of primary care providers in Vermont are employed by hospitals and OCV has distributed the dollars to hospitals but cannot attest their account for where the money is gone within the hospitals. So to summarize, given the substantial loss of enrollment, the declining functions and the chronic underperformance, I can't pass a budget that's so similar to the ones when enrollment was higher and One Care Vermont was attempting to perform its analytic and Population Health functions. So the question becomes what to do about it without harming Vermonters or the primary care providers who've grown accustomed to receiving the support dollars. I'm hoping that we get to discuss that further during this meeting. So with that, I'll turn it back to you, Chair Foster. Thank you. And Dr. Merman. Thanks, Chair. You know, I actually share a lot of the concerns that Tom laid out. Michelle, I actually am very comfortable with the wording of this amendment and the support staff recommendation regarding the funds that are intended for primary care providers, bolstering primary care providers and primary care transformation to be better attested to and accounted for. An area that I've been thinking about, too, that I think is troubling and is actually regarding the complicated, controversial topic of executive compensation. And I've been thinking about this a fair amount. And I wanted to sort of share some thoughts on this. I think this budget is a pretty significant change from the budget that was presented and approved in December, largely the boss of Blue Cross Blue Shield, but the other programs that Michelle and Tom have mentioned. And it's maybe rethink the executive compensation structure somewhat as well. We did receive information from OneCare on how their executive compensation is determined and calculated. So my understanding from this is that OneCare uses national benchmarks. There are several rating agencies to determine a benchmark of an executive compensation based on national similar executives. And from this, they take roughly a 50th percentile or the median to set the base pay and then have bonus pay up to the 65th percentile of their national executive benchmarks. Vermont has a very different situation throughout the state. The median income is significantly below national median household incomes. Cost of living is high. So I've been thinking that this executive compensation up to the 65th percentile of national benchmark seems inappropriately high given the complicated finances of health care at this time, the challenges of access, sort of all hands on deck situation we have of trying to figure out how we can use every dollar the best we can to deliver health care for monitors. So one thing that I would feel comfortable with is proposing an amendment to the budget that would set executive compensation, total compensation, the 50th percentile at the median of national benchmarks for other executives for ACOs, assuming these are large ACOs. Understanding this is a different budget, there's been a significant loss of lives attributed to one care but not an adjustment of the executive compensation there since the prior budget and use that difference to again try to find a few hundred thousand dollars more to bolster primary care support in Vermont primary care transformation. And when I think of what is my responsibility on the Green Mountain Care Board to use money that's been paid for by Vermonters or on behalf of Vermonters for care delivered that has now ended up into one care through hospital dues, it seems to me the right thing to do to take that money and use that to support primary care access delivery transformation over high executive salaries. Tom that's the one thing I feel that I could add to this conversation and I wonder if that helps you feel more comfortable moving forward with this budget. I think you mentioned my name David and executive compensation is one of the things that I have in my notes that I was hoping we would discuss. Since we voted in December there have been substantial changes in the number of lives covered and the core functions of the organization they both reduced substantially. And if we think of variable compensation as an incentive, the incentive to executives hasn't worked. Access hasn't improved. Quality measures have been flat. Some are good but flat. Others aren't so good, haven't risen, and others have declined. So it's hard to understand how executives have been compensated at 100% of their variable compensation now for several years. And so if that incentive hasn't incentivized excellent performance, where do Vermonters need the most assistance, right? It's with we're overusing emergency departments and have access problems to primary care. So could we redeploy some of this money? It's not a huge amount but I think it's an all hands on deck thing to use your terms. Could we redeploy that variable compensation for the rest of this budget cycle and devote it toward that need for primary care? Going forward, I like your idea that makes really good sense about the 50th percentile when we start talking about guidance. So thanks for sharing the idea and letting me comment on it. Great. Thank you both. I'll turn to member Holmes. Any questions or comments? Yeah. Thank you also to Michelle and Russ and the rest of the team. I know it's been a lot of work put into this. I support the staff's recommended motion language here. I think it's important for the board to understand the funds flow from one care Vermont to the hospital and primary care practices. If these funds are simply a replacement of funds that would otherwise have been directed to the primary care practices, then we wouldn't expect to see much of an impact on popular health or additional impact on population health. So we need to see that these funds represent an additional investment in primary care above and beyond what would otherwise have been allocated to support these practices. I do have a question for the staff on the October deadline for the attestation. I don't know why we couldn't ask for that sooner. In fact, it would be helpful, I think, to know about that as we're going into the hospital budget process. And I also like the idea of requesting more detail directly from hospitals on how these additional dollars are spent within the primary care practices. And I would hope that if they did an historical look back at the funds flow to their own primary care practices, perhaps on a per patient level, that we would see a discrete jump when the ACO began making these payments to the primary care practices so that we'd see this as an additional investment in primary care. With respect to some of the other points that have been raised, I think with the addition of the benchmarking analysis, we now have new tools to hold the ACO more accountable. And I think we should. We're discussing fiscal year 24 guidance next week. I would love to see us think about how we can use that guidance to ensure stronger performance. How can we use performance improvement plans to improve specific population health metrics? Can we consider stronger ties to specific quality metrics that are emerging in the benchmarking analysis in the payer contracts, perhaps, if we have that ability? How do we direct population health program dollars towards the clinical outcomes that the benchmarking reports suggest need improvement? And to the degree that we outline stronger guidance on how executive variable pay is tied to specific outcome measures, I think that's really worthy of discussion in the fiscal year 24 guidance discussion, which is literally, I think, next week or the week after that at the board meeting. I guess I'll just weigh in now on the executive comp points that have been raised by other board members. I share concerns that other board members have about ACO performance, and I'd like to find ways to ensure better accountability. And I think I've just outlined some that I think can come through the fiscal year 24 guidance. At this point, I'm not particularly comfortable freezing or redeploying fiscal year 23 variable comp. I have a couple of reasons that I'll just share. One is that we are not an HR department. We don't have access to employee performance data. We don't have access to market level data on compensation benchmarks. Deciding executive comp at this level and at this time with such a limited information to me feels like regulatory overreach at this point in time in middle of the year. Our guidance says that executive comp must be tied to specific and measurable goals. It appears that it is from what we've seen. We may decide, we prefer to see that executive comp tied to different specific and measurable goals, but they do seem to be complying with our guidance. So we can do that in fiscal year 24 guidance so we could tie it to different specific and measurable goals. And I think we should talk about that. My other reason is that fiscal year 23 is not over. So there's new leadership at the ACO with potential to improve performance and change strategic direction. So I guess I would ask, what evidence do we have right now midway through this year that fiscal year 23 executive performance is not deserved of bonus pay that the executive team has not met the specific and measurable goals that their board of managers laid out for them for this year? So we're mid-year and we're already contemplating freezing or redeploying compensation that's already been established for this year. And in fact, we approved the compensation pool back in in December. We knew that blue plus blue shield had pulled out. We knew the bench parking report. So that we had known some of that most of that information at that time. So I just want to make sure that we're within our scope of what we're evaluating here when we're looking at a budget update. And I just want to also suggest that we need to think about unintended consequences. If we begin micromanaging executive bonuses, regulated entities may respond by simply increasing base pay and getting rid of bonuses altogether. And I think that would reduce one lever that the board of managers has to hold their executives accountable and to reward strong performance. So it's something that I think we should consider. So at this point in time, but I am interested in the conversation as it unfolds, I feel comfortable with the suggested motion language. And the only question I would have actually I would add for the staff is the timing of that compliance for the attestation, whether we might make it sooner. Thank you very much. Member Holmes, member lunch. Thank you. Michelle, could you go back a slide, please? Thank you. So I had a question in the documentation that you received, did it only show the shared savings or also the shared losses distribution? The documentation that I reviewed, Robin, was just for population health management. Buns, earnings. Okay. Just what did they have earned over the previous quarter? So it doesn't include the shared savings or losses? It does not. That would be distributed back to the providers. Okay. Okay. I think part of my question about the recommendation is whether it is overly narrow, because certainly you could see if there were shared losses in a prior year that those shared losses potentially got passed along to primary care or perhaps did not. And so having a bigger picture of not just the population health investments, but also the shared savings and losses and how that get distributed within the hospital might be important. And I also think that the language around primary care providers might be a little bit narrow. So for example, the hospital could invest in a different unit, like let's say mental health, which technically may not be in the primary care part of their budget, but may support the primary care provider operationally. And so I think that still fulfills the intent of the funds, even if the accounting flow doesn't go exactly to the department, right? So I think there's a lot of complexity under the hood here, potentially. So I would just want to make sure that the language of the attestation or affidavit is sufficiently broad, that we aren't unintentionally excluding support for primary care transformation that may be technically accounted for outside of the practice level in some instances. For example, I think at one point a hospital had hired scribes to reduce administrative burden and give primary care providers more time to do the care management functions. I don't know that those were accounted for in primary care, they might have been accounted separately. So I'm supportive of collecting the information. I just want to make sure that whatever we collect, what we ask for is sufficiently broad to actually get the intended information and isn't overly narrow. So if people are open to just making sure that I don't think we have to micromanage the language, but as long as if folks are comfortable ensuring that the language ends up broadly broad enough to capture what I think is the intent, then I'm supportive of it. I do think it's quite frankly more important to get the information from the hospitals than from the ACO, but I can go with the flow on this one. Similar to Jess, I think it's more appropriate to, if we're going to change guidance around executive compensation, that should be done in guidance. The core functions in the Blue Cross were known at the time of the budget, so I think I'm with Jess where I would stick with the staff recommendation at this point. Thanks. Thank you very much. Two comments or kind of questions on this hospital primary care payments. I think I would like to have a historical accounting too as to where the money had been going and where it has been used. And in terms of member Lunge's comment about how do you define primary care and what goes to and what's not, I guess I would ask for whatever the hospitals described at the time contemporaneous to it of how they use the money. So not really like now we're going to define it. I'd look to how did they define it before and how did they account for this money before? And if the answer is it hadn't been, then we should just know the answer that it hadn't been and that's something for us to know. And if they had been defining it one way and they wanted to find a new way going forward, fine, let's just understand where it's been going and where it's going in the future and come to some sort of understanding of how it's being defined and used. I think that's really important. So I'd ask for a historical accounting, not just a prospective accounting. And then I think also member Lunge's comment that if there's going to be different types of investment in primary care reported to us, if we need to have a breakout of what it was, like for example, HR support for primary care or the scribe example or something that's less direct, it's fine to get a breakout if that's how it should be best shared. So I agree with this recommendation. I think it's really important. I think if in the fall I was advised that there is a concern that a large amount of this money was not going to primary care, I wouldn't have supported the budget then. And so I wouldn't support it now given that like I now am aware of that concern and those questions haven't been answered yet. Maybe we'll get that answer today. Maybe we'll get it some other time. But I think given how much money it is and that this is a statutory criteria and it's something that the ACO has cited is really critical to their efforts. I think we all deserve and Vermonters deserve to know what actually has happened with this money and we need to correct it going forward if there's a problem. So I really support this. I think it's a very monumental change if all this money wasn't going where we had understood and thought. On the executive cop, I agree with member Merman and member Walsh. I don't view it as regulatory overreach or micromanaging. It's a regulatory budget decision. There's various things that the money is being spent on. And it's our job as regulators to determine if it's appropriate or whether or not it can be used in a better way for Vermonters. I think the 50th percentile seems entirely fair. I think if it was 100th percentile and the executive cop was really, really high, I don't think we'd say the same thing. I think given the context of the performance that we've seen, the benchmarking data we've received, the fact that Blue Cross pulled out, that attribution dropped significantly. The ratio of admin expenses to attributed lives has increased and the risk levels have changed. Those are pretty drastic changes to me in terms of what I thought before versus what I thought now. It is true that I think the week before or a few days before we were to hear this originally in December, we found out about the Blue Cross withdrawal. But we didn't find out a whole lot of the details about it. That didn't come for quite a bit later and the impact of it. We didn't know that. That analysis came quite a bit later. Second, we didn't have the benchmarking data. We've seen that a number of the important things that we are trying to solve for are going the wrong way. Primary care visits are significantly lower in Vermont in the ACO network than the 50th percentile. Now it's worse than it was in 2019 or I should say in 2021. It was worse than in 2019 and wellness visits as well have declined in those that span. I would note that the ACO has touted its investment in primary care, which at the time I thought was great. So the fact that maybe that money isn't going there is a third really, really significant development for me that changes my assessment. I think in our hearing on the revised budget in early May, one of the first things that was said was that the ACO has invested over $100 million in primary care. And as of today, at least right now, I don't know if that money actually went to primary care or not. And if it didn't, it's not really that shocking that we're seeing slipping performance on something that I think we all agree is really, really important. And so given those changes, my question for me is when I think about the executive comp is where is the money best spent for Vermonters paying executives up at the 65th percentile and using it elsewhere to address our problems or paying it sorry at the 50th percentile and using the money to address some of the issues that we're seeing in performance or to get it up to the 65th. And based on the performance and these huge changes in the budget, I have a hard time saying that it should go up to the 65th rather than the 50th. I think that money is best spent addressing primary care or some of the other issues that we're seeing. Vermonters money, they pay a lot for healthcare. It's entrusted to the hospitals and the ACO and for us to regulate it. So I think it's important that we allocate it where we think it's best suited. I think the ACO has a role in saying where that should be and why, but I have a hard time saying it should be invested in executive, high executive salaries in the first place rather than actually in the primary care or somewhere else that's sort of struggling here. So for that reason, I agree with member Merman's suggestion. I also noted when I was thinking about this last night, I thought about it a lot. The care board and the HCA had asked for benchmarking data for a period of years in terms of performance from the ACO and we didn't get it even though it was asked for. I don't think we actually required it until last year and we did get it this year, but it had been requested or suggested prior to that. So there's no benchmarking of performance, but there had been benchmarking of salaries and to me that wasn't quite right. I get it's important, I agree with benchmarking the salaries, but I don't think it needs to go above the 50th percentile in this state for where we're at right now with our ACO model. I think the money can be used elsewhere better. I don't think I had anything else and I appreciate all the members' comments, but that's all I had. Member Walsh, I see your hand is up. Thank you, Chair. I think with I want to express agreement with you about I don't consider addressing executive salaries overreach or micromanagement. We have had existing requirements 5.2 that the measures used be specific and measurable and we in prior meetings ourselves have said they're not. They're procedural. The ones that have been used have been procedural. So it's not that they need to be developed in the that we need to require specific or measurable in the future. We've had that requirement and it hasn't been met. The need for market analysis to help understand what the salary should be, one care's been doing it. They've been at the 65 percent of the market. We have those numbers and that evidence required to make an adjustment, I believe, is the declining core functions and the loss of attributable lives. The operation that's occurring for that business has shrunk considerably. So I don't think it's micromanaging or overreaching. Lastly, there's one other thing that I was hoping we could talk about together and that's the data analytic budget. The move to move analytics to UVM has raised concerns about antitrust. But my understanding is we at the board don't deal with antitrust. So there's not a lot that we can do about it. But it is a $2 million budget item and it appears potentially wasteful because there's no defined scope of work or deliverables. So from a budget management standpoint when I've run my business, I'd say what's the $2 million buying Vermonter specifically? We don't know. And for context, one care has had an analytic budget and a vendor, different from UVM but a vendor, for six years. And if it were $2 million a year, I don't know the previous budgets, but if it were $2 million a year, that's $12 million spent for what product and to what end. And so why should we approve an additional $2 million to start up an unclear analytic work process for a declining organization with an uncertain future? I think we could eliminate that or at least freeze it until we know more about what it's going to purchase. All right. I have a, I wouldn't mind discussing that and I have a response or a couple thoughts, member Walsh. I share the concerns as to like what this money is being used for and what Vermont will get out of it. At this time, I wouldn't be prepared to make a change in the amendment process to that line item itself. I would say that in the fall or in the guidance, I would ask for specific and clear outcomes and results that Vermonters are getting for that investment. We haven't had that necessarily to the degree everyone wants in the past, but we should see what Vermont is getting for that. I don't know at this time that I would say no to that investment, but I would want to make clear that we expect what we expect to get from it. And just sitting here off the top of my head, I would expect the description of how it's used and what the difference is that's made by it being used. So if the product is data and analytics that is distributed out to the network to advise on performance, whatever it may be, that there's some level of understanding of the usage of it and then to the outcomes from the usage, I think those would be important. And if those are good, then I think that the ACO should invest more money in it potentially. And real quick on the executive conf, I think in the guidance, we can put down what we think. And I think, frankly, if the performance improves really drastically on the key things, we should pay for performance. If we're able to really achieve, it doesn't have to be the 50th percentile. That's pretty generous in my mind. That's a high amount of money. But it could be higher if it's outstanding and it could be lower if it's not. But I think that's fair. So anyway, I just want to respond to that comment that you made about the analytics program. I understand your point, but that's where I would be as of now. I appreciate that. And I'm interested in anybody else's comments too. And just with the pay one more time quickly, I have no problem with salaries in general. There have been incentive payments, and it appears to me they've not worked. And there's substantial change in business. And for those salaries to remain at that level, particularly ones that are incentive, the portion of the salary that's incentive-based to remain at that level with such a loss in the covered lives and the core functions, I believe, is wasteful and should be changed. And the money should be diverted to areas of greater need. I'm not supportive of changing the analytics budget because, quite frankly, analytics is an area that we all recognize needed to be improved. And so I think that cutting something that needs to be improved just doesn't make sense to me. So I'm not supportive of that. And I just wanted to say one thing on the loss on the Medicaid redeterminations. Those lives are not lost. They're shifted from the commercial to, or they're shifted potentially, right? So I think we don't know how the redeterminations are going to flow out. Those are really difficult to predict, having been through that, quite frankly, with the Affordable Care Act, where I was looking at how that was going to play out. All of the estimates were way off. So I think we do know there will be some shifts there, but I think it's difficult to predict that. So I think we're going to have to wait and see how that works out. So that's all I'll add. Any other member comments or questions? I'll turn it to the healthcare advocate for any questions or comments they may have. Thank you, Mr. Chair. Mike Fisher here. Well, first off, thank you. Thank you to the staff and thank you to the board members for a good conversation. This is some tough stuff. I can see there isn't full agreement. So first off, let me just say we appreciate the proposal to get some feedback loop to really understand, have a better understanding of where the hospital primary care payments, how those monies are actually being used. We appreciate that and support the motion. I will comment also about executive compensation or maybe more specifically about variable executive compensation. Members of the board, I have to admit I don't get it. I just don't understand variable compensation for executives on this level. And hey, we're at the moment talking about the one care budget, but I mean these comments much broader throughout the healthcare industry. It makes perfect sense to me if you're asking an employee to do something above and beyond or night hours. If you're asking a team to do sort of more than they are asked to do in their job description that you would give bonuses. Hey, you turned a profit. Your team gets a bonus. That makes perfect sense to me. On this level, these well-paid executives getting a bonus for what I would call doing their job. I don't understand it. Maybe I have lived too long in the human service government sector and I can't apply it in any way to my team. I joked with my team earlier, hey, you guys did a great job. You did everything I asked you to do and more and none of you are getting a bonus. And since we're talking about executive pay, executive bonuses, the more absurd thing is because they did such a good job, I'm not going to get a bonus either. So to member Holmes's point earlier, no, I don't want to get rid of variable pay in order to just boost executive pay. I think some concept of a reasonable pay makes sense to me and I appreciate the conversation that's been happening here. And I'll part with a invitation. I've lived too long in the human service government sector my entire professional career if there's anybody on this meeting that wants to give me a call and enlighten me about just why we need to give bonuses. I'm not asking for a response here. I'm here to talk about it because I really genuinely don't understand why. Why board of managers would need that kind of a tool to hold accountable their well paid executives. Thank you, Mr. Chair. Thank you very much, Mr. Fisher. I'm going to open up to public comment. There's two motions out there. So I'll open up to public comment and then after that, I think there's been a little bit of modification of the one motion and potentially we need to write the other one. So I'll take a break after that and we can modify any languages needed during a break. But I'll turn it to public comment first. Hang on. Let me see if I can do. Ms. Wasserman, you have your hand up. Please go ahead. Yes. Thank you. We're generally pleased with the requirement that one care obtain affidavits from the hospitals regarding their use of primary care physician funds. But a question and an addition might be, does this stipulation also apply to one care's new initiative to pay primary care physicians for each patient who receives a mental health screening and follow-up? And certainly my opinion is that yes, it should because it's all same. It's all part and parcel of the same thing. In fact, I think it's especially important since Vermont is in the midst of a significant mental health crisis. And it's easy to ask what has one care done about this crisis? And what I hear is from the DAs and others that very little, very little. In fact, one care's new mental health screening initiative will actually make things worse. There's currently a shortage of mental health providers. And what is one care's response? Well, they decreased funding for the DAs. One care's revised budget this year allocates a measly $700,000 for the DAs. Now $700,000 translates to roughly 70 grand for each DA. And what can you do with the mere 70 grand? Not too much. Nevertheless, the DAs are currently deluged. They're deluged. There are over 700 adults and children waiting for services. Over 700. That's a lot of Vermonters waiting for services. At Howard Mental Health, there's a 180-day wait. And at Washington County Mental Health, there's an 84-day wait. One care's new mental health screening initiative will merely increase the number of people waiting for services. So my recommendation is that the Green Man Care Board should mandate that one care's revised budget increase the funding for the DAs. And most importantly and germane to today's discussion include the new mental health screening money for primary care physicians in the hospitals after David's. So how is the public's interest being served when the ACO's operating costs have grown from $53 to $77 per attributed life while the number of people shrinks? It doesn't really add up. And again, my recommendation would be that the Green Man Care Board should require fiscal prudence and approve a budget with a lower administrative cost. When a hospital-centric ACO, like one care, when is this hospital set? When is this hospital-centric ACO going to implement initiatives to reduce the ever-growing hospital costs? The Green Man Care Board could condition the one care's 23 budget with a stipulation that the ACO address avoidable and unnecessary care. There's some basic approaches to this. You can implement mechanisms to prevent unnecessary emergency room utilization through coordinated efforts with local primary care practices. Pretty straightforward. The ACO could develop initiatives to reduce avoidable hospital hospitals. I'm sorry, avoidable hospitals. I need a glass of water. The ACO could develop initiatives to reduce avoidable hospitalizations and unwarranted hospital lengths of stay. And finally, here we are in year seven, and we do not know how many people the ACO actually serves each year. Starting attribution counts are meaningless. We need the final number of people served each year in order to compare it with the cost. An accountant would be appalled. We don't really know what we're getting for the money spent. We need the actual number of scale target lives served by payer for each of the ACO years, and that's the actual number of lives served. These counts could be then compared to one care's budget and would give us an accurate picture of people served and at what cost. To me, this seems pretty basic, but we don't even have that. So in my view, there's far too little accountability for this accountable care organization. Thank you. Keep your comment. Walter, how are you? Nice to see you. Please go ahead. I think you're muted, Walter. It was unmuted. Nice to be back. I was going through withdrawal symptoms for a while there. It makes one of us meeting. I just, not too much here. I fully agree with what Tom and what Dave and what Owen has said, especially the parts about the care board does have the regulatory authority to basically step in and regulate the executive pay. I agree wholeheartedly with Mike Fischer's comment. Why do these people get bonuses? As an employee, I don't get a bonus if I go above and beyond what I work. All I get is maybe an extra hour's pay and that's it. It might pat me on the shoulder or something like that, but no bonus. So why do we even bother with this? My overall question is, given all the comments, I also agree with the staff recommendations about requiring the hospitals to submit accountability reports on where this money is going. And a good place to start with this is a recent commentary in the Vermont digger by a name I cannot for the life of me pronounce, Abedik Govic and Bushway, eye-opening conversations affect hospital talks about that you can probably understand a little bit of where that money is going. It's going to the top again. I think the overall question I think we should be asking is, is one care really necessary? It, you know, Julie's accountability, all the questions the board has raised about it is, what's the point? I'll drop it there. All right. Thank you very much, Walter. Ms. Guttwin, your hand was raised next. Thanks. It seems like from many perspectives, the ACO is on thin ice and it's been getting thinner. And seems like what's melting the ice, you've been discussing. Executive compensation, it isn't just about how much they get paid. It's, are they doing the job that they're hired to do? And I don't hear any evidence that they are. And I'm also concerned that there's probably conflict of interest if the UVM Health Network is involved in analytics. I would think it needs to be an independent organization that doesn't have anything to gain in the results. I'll just leave it at that. And the observation that primary care, which we all agree is important. The compensation is vastly higher for hospital-based primary care without any evidence that there's anything to be gained from that. So this ties into what I've brought up in the past. And it's not about equal pay or fairness and pay. It's just common sense. Why would we pay more for something that we get no added benefit from? And then the last thing is that I see nothing in the discussion about the actual treatment of what is most prevalent in adding cost to health care and in one care. For one care to work, it's got to improve health. And while primary care is vital for getting people in to know where people stand and their status, they take tests, blood work and they can diagnose. But the only treatment that a primary care office can offer is, you know, through the primary care doctor is a prescription pad. And they can prescribe medications, but those don't treat the disease. They treat symptoms of chronic disease. And investing in mental health, like I heard, is one way to cut costs in health care because our minds are connected to our bodies. And we should be investing more in mental health. But the other thing that we should be investing in is physical therapy and using physical therapists to prevent injury and to prevent the complications like surgeries because research shows that the value of physical therapy far outweighs the cost. I see nothing in the affordable care organization that even addresses physical therapy. I think probably we fit under specialist, which gets a big fat zero. So it feels like I'm in too small a group to matter. Even though if I talk with each of the board members, I'm going to hear, of course, you matter. What you do matters. Your opinions matter. What I'm saying is not from a selfish position. It's common sense. If we can invest in people's health and wellness and prevention, and prevention isn't in a drug and chronic disease. It's in three components, physical fitness activity, mental fitness, and nutrition playing a part. And I think that unless these three components get the financial support, I think the ACO is not going to show any value. And like Walter said, what's the point? Thanks for listening. As you always do a good job, Dewey. I appreciate it. We appreciate you sharing your thoughts very much, Ms. Guttwin. Thank you for attending and sharing your thoughts because they're always helpful. And Mr. Berman, I know who you are. We haven't had a chance to meet, but usually I try to make sure folks are from a regulated entity or associated one that they introduce themselves as such. But please go ahead. Absolutely. I'm Abe Berman. I'm the interim CEO for One Care Vermont County Care Organization. Appreciate the opportunity to speak to you, Foster, and the rest of the board. First off, I just want to say that everybody at One Care is a fellow Bermont and we share the board's interests in this work. I appreciate all of your passion and I share it for this topic. I'm in this role for that very reason. I want to see better outcomes for Bermonters. I want to see a sustainable delivery system and costs that we can all afford to pay. I'm accountable to the One Care Board of Managers in this role. My compensation, the compensation of my team is set by the board as any organization sets its compensation, whether informally or formally. We use benchmarks to do so. I appreciate the dialogue around this. I'd ask the board to consider, as was pointed out by member Holmes, that the board of managers has purview and rule five to set this compensation and to do so with the market in mind. I appreciate all of the concerns around it and I would just say that none of us are here for the money. We're all here for the mission and what we want to accomplish in this role. That said, all of us, like you have families and obligations that we have that we use our salaries to support. Further, I wanted to point out that there is an interconnectedness between the ACO and between all the participants within the ACO hospitals, providers alike. We're working with them to accomplish these goals. I certainly agree and appreciate that the dollars we set aside for primary care and population health management, we want to see used for that purpose. Again, I'd ask the board to consider when they vote what the best mechanism is to ensure that those dollars are used for that purpose and I'd underscore what members Lunge and Holmes discussed when it came to the dollars and the accounting behind it is not as simple as it might seem. It's not a matter of just putting $1 towards a certain staff member. There are lots of different ways that these goals can be accomplished by complex organizations like hospitals and hospitals that employ providers. Beyond that, I look forward to partnering with all of you to do this work. I'm here to ensure that our strategy and mission guides us and that we, to your point, set actionable goals with realistic metrics and measures that we can report on later to show our progress. I believe we've done that in historical fashion in voluminous ways, but we'll continue to do so and to work with you in the best way that we can to get this work done because it really is important work. Thank you for the opportunity to speak. Thank you for raising your hand, Mr. Berman. I was remiss not to congratulate you on your appointment. Congratulations and we look forward to working with you as well. I'm glad that you've taken the job. Surely a heavy lift like all of ours are. So congratulations. Thank you. Of course. Why don't we take a 15-minute break in case there needs to be changes to some of the motion language? We'll come back at 2.30. Thank you. All right. We'll turn now to the Medicare only budget guidance presentation. The motions about the one care revised budget are still being drafted, so we'll go to this. And then we'll take up the motions later. So I'll turn it over to Ms. Bowles, our health policy advisor. Thank you, Chair Foster. And I am joined by Michelle and Russ for questions on this one as well. Let me just get my green chair set up. Are the slides showing up for folks? Great. Thank you. Okay. Shifting gears, since we have so many ACO things in one day. We are here to talk about the Medicare only ACO guidance for FY24. So in terms of what we'll cover today, we have some background. I will summarize the updates to the Medicare only guidance that the staff is proposing. And then there'll be time for board questions and discussion and public comment. And I have a more in-depth timeline, but the potential vote is scheduled for a week from today, June 21st. So at a high level, I just wanted to show this chart again to kind of ground us in what we're covering today. On the left-hand side is sort of the flowchart for ACOs that work with Medicaid or commercial insurers. And on the right-hand side highlighted is what we're talking about today, which are ACOs that plan to accept payments only from Medicare. So as you can see, Medicare only ACOs, which is how I'll refer to them, do not require certification. But they do require a budget review. And then within that, depending on the size of the ACO, greater than or less than 10,000 lives dictates the standards that are used. So for ACOs with fewer than 10,000 lives, the standards and processes, the reviews based on the standards and processes that the board deems appropriate. And so that is what we, that pathway is what we are talking about today, which is the Medicare only guidance that we are reviewing. So again, on the timeline, we, in April and May, the staff went through last year's guidance. We made updates and worked with the Medicare only ACO and the HTA for any input that they had. And of course, today we are here presenting it. And next week we have the potential vote scheduled. There is also a public comment noticed on our website under the public comment section with links to the materials. And we request that comments be submitted by Monday, June 19th in order to allow enough time to be considered ahead of the potential vote. So I'm going to turn it over to Russ for a couple of slides just to further ground us in the context here. Thank you, Julia. So these are slides that the board has seen before in reviewing some Medicare only ACOs in prior years. The first is just kind of orienting the board within the context of our regulatory framework. So under the statute, if the ACO is accepting payments only for Medicare, certification isn't required. It's only a budget review. Secondly, under the statute, there's a threshold of 10,000 attributed lives in the state. Above that threshold, the board has to consider every statutory factor. Below that threshold, the board has discretion to consider the statutory factors that are appropriate for the size scope and operations of the ACO. So for this guidance, we are in the green box at the far right corner. And next slide. And this is the third year that the board has reviewed and adopted Medicare only ACO guidance. To date, there have been two Medicare only ACOs. There was Clover Health Partners and FY22, but did not participate in Vermont and FY23, and the lower health that entered the market in FY23. An important consideration for this type of ACO is that they're operating in a Medicare program that has established tracts, options, and other parameters that are set by CMS in rule and regulation. So the ACO will have some ability, depending on the program, to select which track or which option they're pursuing. But the board's review really reflects the fact that these ACOs operate in established Medicare programs. Next slide, please. So with that in mind, under the statute in the rule, the board is tasked to review and approve or modify an ACO's budget. As I just said, a lot of the programmatic elements of the ACO operations are set by Medicare. So they aren't elements that are really left to the board to approve or modify. And lastly, an important distinction in reviewing this type of ACO is that in many cases, though not necessarily, but in many cases, the ACO has a large national operation of which Vermont is some percentage, and that percentage and amount can vary. But the board's review is really focused and targeted to the ACO's operations within the state. Next slide, please. I think I will turn it back to you, Jordan. Perfect. Thank you. Great. So I, shifting from background, we're going to go into talking specifically about the F-24 guidance draft. I wanted to start at a high level and talk about our approach. As Russ said, this is the third year that we have had this guidance. So at this point, it's pretty well established in that it's written sort of generically so that any Medicare only ACO could complete it should they come to be operating in Vermont. But over time, there's just been questions that we've decided to clarify based on having to do follow-up in past years. And then additionally, as we continue to better understand full range of Medicare only programs that are out there, we've tried to adjust language in the guidance to be more inclusive and not using terms as specific to any particular Medicare only program. So the changes reflect that approach. And then also for kind of usability sake, we've added, I think the biggest change is just the addition of a financial template, but it's not new content. It's just taking financial data out of a narrative where it was a little tricky to work with and putting it into Excel. So just kind of continuing improvement across the guidance. Again, just for reference, these links go to the page with the various drafts. There's a red line copy and a clean copy and then the appendices. They can also be found linked on the public comment page. And these slides are linked on the board page. So there's lots of ways to track down these documents. And throughout the presentation text in bolded blue is what I'm using to describe changes. So going straight into the actual guidance. The first section, there were not any major changes. There were a couple of small rewordings, but nothing rising to the level of highlighting. In section two, the second question, we clarified the timeframe. Appendix A2 is asking about network changes. So we just made it more clear that, of course, you can't talk about network changes if you're new. So saying like for ACOs that have been, that have passed years to comment on. Sections three, I noticed I think should actually say question five, not question two. Sorry, actually it should say question six. But we just added a sentence there asking about how attribution is calculated as we learn more about different ACO programs. There's just different ways that ACOs might choose to report attribution. So we wanted to specify that. Moving on to section four, this is the financial section. Like I mentioned earlier, we added a financial template. So question five, if you're looking at the red line version, it looks like there's a lot of changes and that we've removed a lot of information, but that information was not cut from what we collect. It was just moved to an excel sheet for more usability. And we also, in the spirit of trying to be more general with the phrasing to encompass different medical only programs, make a tweak of how we talk about the phrase providers so that different ACOs can use the terms that are applicable to their program. Section five is the model of care section. The main changes here were some reordering and rephrasing of questions and also removing certain questions that were too specific to particular ACOs. We used to have some questions about referrals that sort of implied that that was central to the model, but we've learned that that isn't always kind of, that that's a choice by the ACO to focus on. So there's opportunities to comment on those types of things in the question, the more general questions that we have. So again, if you look at this section, it looks like at the end that there's some questions that have been cut, but they actually were specifically question one is a rephrased version of what used to be a later question. We thought it made sense to start out asking the bigger picture question of what is your model of care. And then going into the really detailed questions, if you look there, questions with like parts A through H type questions, and that's questions two and five. And for those, those questions pull from language in rule five. And we made some tweaks from that original language just to phrase them more directly as questions to try and make, yeah, just to try and make it clearer. And finally, question seven in this section, we, this is the question asking, does the ACO benchmark performance measures against similar entities? If no, explain why not? If yes, we added what specific metrics does the ACO track and benchmark and how and the rest of the question that was there is and how does the ACO use the results? So we added this question because the board across our ACO oversight oversight processes has had more of an emphasis on benchmarking. But notice that these ACOs are newer, none of them have been in Vermont for consecutive years to date. We wanted to just start understanding what type of data they have on top of the quality data that they're already, that they're already reporting to CMS or CMMI under the models that they're part of. In section six has a number of tables about financial and quality metrics. We just clarified the instructions making it more clear that we're asking the ACOs to denote which metrics are included in whichever Medicare program they are participating in. So again, I just had the timeline for reference highlighting the potential vote is scheduled for next Wednesday. And with that, I will turn it back to you, Chair Foster, for any questions or discussions. Thank you both very much. Turn it to board member questions or comment. I'm happy to lead off if that's all right with you, Chair and with Julia. Yeah, we can just keep the same order for board members, that's fine. Okay. Thank you, Julia and Russ. I have one comment from the presentation and hoping we can discuss it. That's with section five and question seven, but we're possible to pull those back up. So if the organization benchmarks performance, I think sometimes we tend to think of benchmarking as comparing our organization or one organization to another, but it's possible to benchmark yourself over time. And so rather than say, do you benchmark yes or no, and what do you benchmark? Tell us please. I think we might be better served by requiring organizations to benchmark themselves over time. And when I think of that, I start thinking about what do we expect an ACO to be able to do? ACOs, you try to improve communication and care coordination so that you keep people who could be healthy, healthy, and people who have chronic conditions, those are cared for in a way that they don't end up in the emergency department and with requiring inpatient stays. And we have data in our state not just with one care, but across the state that we have a high level of emergency department visits that could be considered potentially avoidable. And we have an access problem with primary care. So I think we'd be wise to ask any organization that's coming in to try to do care coordination to report to us how many ED visits are occurring in their covered lives, how many inpatient stays, and to use the known metrics about ambulatory care sensitive conditions that we create a table, ED visits, inpatient visits, ambulatory care sensitive condition care quality, and ask every organization to fill that out each year. That's short, that's the list of less than 20 measures. And if they provide that, if we require that data and they provide it to us, it's pretty simple to then make the table to show how they're performing over time. So I'd hope that we could be more specific about our requirements rather than do you benchmark yes or no? If yes, tell us what you measure. I think we might better serve our role if we say please measure these things and report them to us yearly. Any other board members have questions or comments? Julia and Russ, thank you for a very thoughtful job on revising the guidance. I thought you did a good job. I guess what I would ask is for, sorry to give you work, Russ, but an analysis of whether what Tom is asking for is within our jurisdiction given the venue issues with particularly national ACOs and potential preemption given that these are Medicare programs and have existing quality metrics specified. Not right now, obviously, but before we vote. I don't know if it would be appropriate. Could I ask just some clarifying questions? Yeah, well, let me flag if this is legal advice or a quest for legal advice, remember Lunge, we should probably do that in executive session. Yeah, I don't think this is legal advice that I'm giving it. It's more, I just want to make sure around terminology because when we're talking about ACOs and we use the term benchmarking, I think that's often used to me and you take the ACO's performance against some external third party source. And so I think the question and the guidance when we had drafted that initially a couple of years ago, it was trying to understand what that external third party source that an ACO had used or was using or if there wasn't an external third party source that the ACO is using to compare its performance on metrics against. So, but I think and member Walsh, please correct me if I'm misstating it. I think what you are saying is there is a should be a table of metrics that the ACO is required to collect and report to the GMCB and that would be relative to the ACO's operations in Vermont. Yes, and thank you for clarifying. I was trying to point out that asking an organization to collect data and report it to us on its own over time is a way of quote unquote benchmarking performance. It's different than what you described as having a third party assess the organization compared to other organizations. And so I'd like to work with you about clarifying that language because they are two different things. Thanks very much. And I'll follow up member Walsh about the legal question. I think that analysis is determined a little bit by how we envision using the data once it's reported. So I think that that one is not one I will answer on the fly. Thank you, sir. Member Lunge, do you have anything else? I do not. Thank you. Great. Anything else from the board? Okay, great. I'll turn to the health care advocate. Good afternoon. Sam Paich, office of the health care advocate. I just want to thank Julia, Russ, and Michelle for your work on this. I think a lot of the a lot of really good work went into this guidance this year and also last year. So we support it. And I think member Walsh makes a good point about the benchmarking. So we'll look forward to seeing the results of that analysis. But I think it's again, really great job. So thank you. Great. Thank you, Mr. Paich. I'll open up to public comment. I see none. So we can move on. And thank you, Mr. McCracken and Ms. Bowles very much. So Russ, how long would you like for a break and to work on the motions? Would 15 minutes be acceptable to be on the safe side? Let's make it 20. We'll come back at 320. You haven't had a break. Let's do 320. All right. We will take a break till 320. Thank you. Great. Okay. We can resume the hearing. Mr. McCracken, if you have the potential motions, would you put them up, please? Okay. I'll move to condition the approval of the amendment to one care as fiscal year 23 budget on the requirement that one care obtain affidavits slash attestations from its applicable hospital network participants to establish the use of primary care provider funds, both on historical basis and prospectively consistent with the intent of the Green Mountain Care Board discussed today. One carousel additionally require its applicable hospital network participants to provide an historical accounting of use of such funds. GMCB staff shall prepare the affidavit attestation form and review the form with one care. I just need one minute to just digest, Owen, and then I may second, but I need to read. Can I ask, were we going to discuss a timeframe on that? Yeah, that's what I was, that's my question. I agreed with Jess's comment earlier that it would seem October 1st seems a long way off for this. I think a friendly amendment to, or I'll amend it, I'll amend it myself to August 1st. I'll second your motion, Owen. Before we, well, I'll wait, sorry. I have a challenge with August 1st, which is that that requires the hospitals to do a significant, like the hospitals are going to have to do some work here on the reporting at the same time that they're submitting their budgets. I think that's potentially true if they haven't done it already. And I don't know the answer to that, although I sort of suspect based on the discussion, they probably haven't. Member Lund, would there be a time that you think would be more appropriate? I think it's fine to have, like, the affidavits and attestations come in by August 1st, but I think there needs to be sufficient time to do, if you're doing multiple years of accounting, that's not going to be a five-minute task. And I think that we would, I personally would rather ensure that the hospitals are focused on the budget process in July and August. And I'll also say that it's entirely possible in order to do the modeling that we need to do for the CMMI response later this fall, that we're going to need to do an additional data request from either payers or hospitals. We don't know that yet. So I'm fine with, I would personally rather wait on the accounting because I think there are particularly the historical accounting because I think there are more pressing and immediate needs that we have from the hospital system. So I would give more time for that. I don't know what the appropriate time is. I would delegate that to be worked out with between staff and the regulated entity or potentially with one board member involved if people are comfortable with that. I don't feel like I have enough information to dictate the timeframe. Yeah, I think myself, I don't really have a great sense of what they have done in the past on this or happened or how big of a lift it is or isn't because I really don't have a great sense of the burden. But I think your point is kind of well made. I think historical accounting, I don't see anything changing in the immediate future based on the historical accounting other than it provides important information. And maybe we need to change what we do going forward. But I don't think like the next week we're going to take up a motion and do something different. So I don't know that there's a huge urgency. October feels very far off to me. October feels right around the corner to me. There's a lot of work between now and October, especially when you add in the federal stuff that we'll be hearing about later this month. We had the historical accounting for December first and the affidavits for August first. Yes, my concern with that would be, I don't know that they're going to be able to attest without having done the work. I think Robin makes a really good point. And I'm not a financial officer. But this is accounting, not like a completely out of the blue strange task. And I think we need the information, the affidavits and attestations before we start deliberating and voting on on care's next budget. So I don't think December works. Remind me, we get one cares budget. Is it October 1st, September 30th, somewhere in October? Correct. October 1st. And typically the hearings are in November and the deliberations are in December and the votes at the end of December. Mine and Dr. Mermin's one year anniversary. I guess given all this, I think those points are all, I guess I am okay with it on October 1st. I think Tom's point is a good one too that it would be helpful to know this when we receive the new budget. So that gives three and a half months to do it, which I think is a good amount of time. I'd second the motion with October 1st. Is there any other board discussion on this? I guess I wonder if we can separate out the perspective from the retrospective on timing. And so far as it seems reasonable that we could have the prospective attestation be sooner potentially for the hospital budget season, say August 1st, that this will make sure that hospitals prospectively use these funds as we've defined and then have the retrospective component in October to see if we have what the historical use of these funds is has been. Does that sound to people? I think it makes sense. To me, Dave, the question I would have though is an attestation from the hospital to the ACO through the ACO regulatory process appropriate to use in the hospital budget process? Or is it more appropriate to ask the hospitals directly in the hospital budget process for use in that process? I feel like you're in a better position to answer that question than me. I tend to defer to legal because even though I am a lawyer, I'm not our general council or our lawyer. So but I mean personally I would ask them directly in the hospital budget process. That just seems more direct. Not that we shouldn't also, you know, I'm a big fan of alignment across regulatory processes. So I think it's okay to get the attestation through this process. But I think if we want to question the hospitals about the use of it in the hospital budget process, we should be talking about that as part of the hospital budget process. I would agree it's appropriate there as well. I think in some level, one care is giving this money to the hospitals. They should be receiving assurances given the concerns that it is going where it needs to be going. So whether it's used or not, I think it's used by one care to assure that when they're paying out the money it's going and being used how it's intended. So if we were to put this, so say we were to have October 1st as the deadline with referring to the one care hospital budget process, but then have an amendment to our hospital budget guidance or just sort of send an additional question to hospitals as part of the hospital budget guidance to account for this money as part of the hospital budget review process. Is that a reasonable suggestion for us? There is some ability for the board to ask follow-up questions of hospitals during the hospital budget review process without having to go through the process of adding that into the guidance. But I think if I'm hearing it correctly that otherwise seem reasonable from a legal perspective. Member Holmes, do you have any thoughts on this? No, I mean I think I hear what all you're saying about the timing of it. October 1st is fine. I understand the potential administrative burden that this might impose and so we want to make sure that the hospitals have enough time to do this. I think we can ask some questions during the hospital budget hearings about the use of these funds as well. So I'm okay with where the board is going, seems like. Yeah, I don't necessarily view it as too much burden. It's something they should have been doing anyway or they know that they happen. So I mean if it's burden it's because they didn't potentially know where the money was being used or it wasn't being used there. So I don't see it. I'm not too concerned about the burden, but I think three and a half months to October 1st. It's long but that's the better way to go. I'm okay with leaving it as October 1st. So I kind of forgot where we are in the process. There was a motion. There was a second. I forget where I amended it. Russ, can you direct me as to where I am in this process on this motion or where I should be? When I just start over. Maybe so one way to do it is to withdraw the motion and start over and specify October 1st. The other way would be to offer an amendment to the motion to specify the date of October 1st. Okay. I'll amend my motion to as it's written in paragraph one on this slide with the amendment to add October 1st as the deadline for the affidavit attestation and the accounting. I'll second. All those in favor, please say aye. Aye. Aye. Aye. And the motion carries unanimously. Thank you. The next one relates to the executive compensation. I think there's a really robust discussion about it. I can see arguments that it would be appropriate to do it in guidance. I would say that if we can do it in guidance and we can do it here, it's our choice which one's appropriate. To me, the organization's changed quite a bit since that original budget. They don't have Blue Cross. They have a lot less lives and there's additional information that's come out. So I don't think retaining executive compensation where it was above the 50th percentile makes sense at this time. I think that money can be used for Vermonters in a better place and I appreciate the sensitivities around it but to me the bottom line is what's best use of the money that's available for Vermonters. So I'll move to condition the approval of the amendment to One Care's fiscal year 23 budget on the requirement that One Care modifies fiscal year 23 budget by capping the total compensation for One Care's executives VP level and above at the median 50th percentile of the benchmark used by One Care to establish its executives compensation amounts budgeted by One Care for executive compensation in excess of the median must be allocated instead to One Care's population health activities. A clarifying question if I may we had talked about base and variable compensation and I don't see that broken out here and is that on purpose and I would like to hear more about the thinking behind that if it was on purpose. Yeah I made the motion so I would say that it is on purpose and that if One Care wants to continue to have the incentive comp I don't really as a matter of principle have a real concern about incentive comp I think it can be productive so I think I would leave it to their discretion as to whether or not they want to include an incentive component to it but the total I don't think should be above the 50th percentile of the benchmark. I see okay thanks for clarifying I'll I would second pending further discussion. Is there any other board comment discussion. I'll just say you know I'm going to vote no on this motion I don't feel comfortable since this was not in our guidance I think it's important for us to be consistent with our guidance I totally get you know you guys weren't here when we did the guidance so you're having to live with other people's thinking and I can appreciate how frustrating that is but I don't think it's appropriate to do it in a mid-year budget adjustment and so that as well as I do think it's overreach and reaching too far into HR details so I'll vote no. Any other member discussion and Ms. McCracken would you take a roll call vote please. I'm going to call the roll in alphabetical order member Holmes. No. Member Lunge. No. Member Merman. Yes. Member Walsh. Yes. And Chair Foster. Yes and the last motion I'll make is to move to amend one care Vermont's fiscal year 23 budget approval to reflect the revised budget submitted by one care on March 31st and presented to the Green Mountain Care Board on May 5th subject to the conditions set by the Green Mountain Care Board today. I'll second. Any board discussion. The only thing I would say is that I am optimistic for one care overall I know I've said this before but I think it's worth reiterating that I think this benchmarking data really helps and I think there's an opportunity here and I'm really glad that we have that opportunity because I think it can make a difference and I want it to and I think it's going to in the future and I hope that we get there. So I will call the vote on this third motion. All those in favor please say aye. Aye. Aye. Aye. Motion carries unanimously and it's approved. I think that's all we have. Is there any old business to come before the board? Any new business? And is there a motion to adjourn? That moved. Second. And all those in favor please say aye. Aye. Aye. The motion carries and it's adjourned and it's a really gorgeous day so I hope everyone gets outside and has a nice afternoon. Thank you.