 It looks like we have everyone's call to order the Green Mountain Care Board's meeting of May 5, 2023. Today, we have a hearing relating to One Care Vermont's final budget, and we'll turn to that shortly. But first, I'll turn to Ms. Barrett, our Executive Director for her report. Thank you, Mr. Chair. Briefly, I want to remind everyone that the Board is going on the road. We went on the road at the end of last year out to Rutland. On June 7th, we will be going to the Morrisville area, Lemoyle County. The details and the agenda will be posted shortly, but we'd encourage folks to come and participate in an in-person meeting in Lemoyle County, and we are very excited to meet those community members. I also want to remind folks in terms of public comment that we have extended the public comment period for One Care Vermont's revised budget until May 24, and that information is on our website. And for those who wish to comment, please submit those to the Board so that they can consider them before their vote. And then last, but certainly not least, is the ongoing public comment period with the next potential all-payer model, accepting comments on those which we share with the Agency of Human Services and the administration as they are leading those negotiations for the next potential model. And with that, I will turn it back to you, Mr. Chair. Thank you. And we had a meeting this Wednesday, Mark Hage, and presentation on reference-based pricing. We have those minutes from May 3rd, so I'd like to take those up. Is there a motion to approve the minutes of May 3rd, 2023? I'll move approval. Second. All those in favor, please say aye. Aye. Aye. Aye. Chair Foster, I will abstain since I wasn't here, but I will be watching the recording. Great. Thank you. And the motion carries and the minutes are approved. I believe we have everyone from One Care here who is presenting. And I'll turn to our attorney, Russ McCracken, to swear the witnesses and then we'll turn to their presentation. Thank you, Chair Foster. Before I do that, I just I want to make one note that I know folks are being admitted through the lobby for this meeting, but as people come up, we're admitting them. So just for the record, I want to note that. For the One Care team, who from One Care is going to be speaking today? So from One Care, Vicki Loner, CEO, Sarah Berry, Chief Operating Officer, Tom Borey, Chief Financial Officer, and Dr. Kerry Wolfman, Chief Medical Officer. All right. Thanks very much. I will swear you in with the oath prescribed for witnesses. If you would raise your right hands, we'll do it all at once. Do you solemnly swear that the evidence you shall give relative to the cause now under consideration shall be the whole truth and nothing but the truth. So help you, God. I do. Yes, I do. I do. Thank you very much. You're sworn in and I can turn it back to you, Chair Foster, or just over to the One Care folks to proceed. I'll just say hi and thank you all for being here. I reviewed your slides. Thank you for getting them to us the other day. It was helpful. And I'll turn it to you. The staff informed me. You've asked for an hour and a half of your presentation, which sounds great. So we'll go through your presentation till about 10 a.m. ish. And if you need a little more time, fine. And then we'll take a break, I think, after that and then turn to board questions. So thank you all for being here and we look forward to your presentation. Great. Thank you, Chair Foster and members of the board, while the staff, oh, they're really quick at queuing things up. I wanted to say a few opening words before the management team really walk through the budget modifications that have been made and that we're happy to present to you all today. Just to put this into context, this budget, One Care was formed by Vermont healthcare providers for Vermont healthcare providers to be able to succeed in value-based care arrangements. As you all know, healthcare is hard, messy, and complicated, and the work has been all that through the years. And we have really assembled a coalition of voluntary and willing providers that are 5,000 members strong. And that's something that we should be proud of as a state in a coalition of healthcare providers. We've made progress on several fronts in terms of savings in the public space. We have invested through our collective resources over $100 million in primary care. And even though we've had some speed bumps along the way, we've been able to turn about a billion dollars into value-based care arrangements over the five years that we've been working with the state under the all-payer model agreement. I think we're at a critical point at One Care, Vermont, and our board is currently engaged in a strategic planning process to assess how we are most effective moving our work forward as a provider coalition. I have great faith in our board of managers at One Care, Vermont. We have over 20 practicing healthcare providers and executives and four consumers that deeply care about the work that we're doing in Vermont and are going to do their best by Vermonters to provide for the best care, the right time, the right place. And so I'm proud that I've been able to be part of that effort. Today, you're going to hear from our management team about the budget that we're here to present for you. That really is the shared resources of Vermont healthcare providers so that they can engage in healthcare reform efforts. So with that, I'm going to turn it over to Tom Boreys, who's our Chief Financial Officer. Thank you, John. Thank you, Vicki. Good morning, everyone. Happy Friday. All right, so we're here to discuss our revisions to the 2023 One Care budget to set the table a little bit for the board, as well as the public listening in. We submit a budget to the Vermont Care Board in the fall of the year preceding the fiscal year performance year. That budget contains many estimates and a few years ago we established a process by which we would come back to the Vermont Care Board in the spring and communicate any material changes that occurred through the negotiating process with payers to the regulatory process or just through the passage of time. So we're here to discuss those changes with you. We have a lot of ground to cover. Today's actually the next slide, Kelly, please. We're going to start with some general budget updates. This is really the number side of the discussion, at least the financial side of the discussion, what has changed since we submitted that initial budget, and then we're going to delve into some notable changes, which are a little bit more discretionary in nature and reflect responses to some action that happened last winter and early this calendar year. All right, with that, let's dive in. Next slide, please, and you can skip one more. Thank you. All right, we're going to start with attribution. That's where all of our work really begins. That's the attributed lives that are assigned to one care providers. As you can imagine, with the absence of a Blue Cross contract, which I'll come back to a little bit later on, the attribution counts are down by about 65,000 lives in total. A couple of other observations I'd like to share. Medicare attribution came in a little bit stronger than anticipated. We assumed around 67,000. It came in around 68, so slight uptick there. Bigger news in the Medicaid space. Medicaid attribution came in quite strong relative to the initial estimates that we prepared last summer. Some of this is just the way attribution works. We're a recipient of attribution, and we're trying to guess as best we can the number that will come through. But we also did some very deliberate work in partnership with Diva to refine the attribution methodology and ensure we're capturing everybody who should be captured through the attribution model, and particularly affected FQHC. I think that was a really good outcome that we were able to get a little bit more out of the Medicaid attribution run. Commercial, you can see going down quite significantly, 83,000 fewer lives in the initial budget. Much of that is due to the Blue Cross decision and outcome. We do have a new self-funded program included in this budget that we'll speak to a little bit later that restores some of the lives that were lost, but certainly not all. Lastly, quick note on Medicare Advantage. It's been a hot topic in the state over the last few years. When we get our initial attribution run for Medicare, it is before open enrollment. Essentially, decisions are made by people who might choose a Medicare Advantage plan. We have that 68,000 life initial number, but then a number of those lives before the performance hearing begins will select a Medicare Advantage plan, which means we actually start the year with fewer lives. We projected in our budget starting around 53,700 lives. Ultimately, after the Medicare Advantage migration, we're starting with 54,321. Pretty close to the initial budget, but just wanted to show that change from 68,000 total lives initially down to 54 that will actually be in the program throughout the year. That's solely by their decision to choose a Medicare Advantage product over traditional Medicare. Next slide, please. Blowing from attribution and a product of the final total cost of care targets, we have our total cost of care targets forecast. I call it a forecast because it does still move throughout the year. Many of these have dynamic elements to them. Medicare is down, just an update to the target there. It looks like a big number, but it doesn't take much on the target space to really change that number. I'd call that a somewhat ordinary change there. The blueprint amount remains the same from the initial budget, no change in that space. In Medicaid, I want to note that we worked with Diva this fall and winter and decided collaboratively to consolidate the two cohorts into one target. When we first began with the Medicaid expanded population, it was a new concept for us all. So we really worked to segregate or separate those two components, have a target for the traditionally attributed, target for the expanded attributed. Through time, we've gained some comfort in the data dynamics and decided to consolidate into a single target. This simplifies life for us a little bit, means we have one settlement rather than two, one risk corridor, so everything kind of rolls into one. So you'll see a little bit of juggling between the categories, but if you net out the Medicaid rows, there's actually an increase there, largely due to the increase in attribution. Next, Blue Cross, you can see that total cost of care leaving the accountable care space that turns to a zero. MVP is down a little bit relative to what we budgeted. Attribution came in a little bit lower than we expected there as well. And then lastly, very last row, you can see the self-funded initiative bringing about $63 million of health care costs back into an accountable framework. Side please. Fixed payments, we supplied targets to the Green Mountain Care Board previously, indicating where we think we can land in the fixed payment space. To go through them, each Medicare and commercial, we've projected zero percent, essentially, because any fixed payments that we've had for either of those different lines of business have been reconciled to fee-for-service. Our preference is of course a true fixed payment that does not reconcile the fee-for-service. We projected a 51 percent, that 51 percent of the total cost of care in our contract would be converted into a fixed payment. In 2023, it actually landed at 57 and a half percent, so we've exceeded that target. Also note, in more exciting space, that we continue to discuss the possibility of a fixed payment expansion with Diva to broaden the scope of the fixed payment arrangement for Medicaid covered lives. I am hopeful and excited that we can get this program to land either this year or next year. Side please. Total risk. As you can imagine, with the absence of the Blue Cross contract, total risk is down. It was originally $36 million, now down to $26 million. Notable changes are really just a flow down from attribution, total cost of care. We did agree with Medicaid to a blended three percent risk corridor, so as part of the consolidation of those two cohorts is now we have one risk corridor in the past we had two, so that was a slight change, and then commercial just flows accordingly. It's always been a little bit challenging to display the blueprint, sash, advanced shared savings risk element, so I've just put that off to the side on the right there so you can see that amount. We've discussed that much over the last couple of years, certainly complicated factor in the program, but you can see that $9.5 million off to the side there. Next slide please. This breaks down the risk by health service area, and to go through this quickly, the first two columns, the left most two columns under the blue heading represent what we call the accountability pool. This is the way in which we incorporate primary care of all types into the risk sharing model. We segment it into non-hospital PCPs, which is going to be your independence and your and then hospital PCPs separately. Next column is the risk-bearing entity share that's essentially the amount the hospital takes on on behalf of the HSA beyond the accountability pool, and that results in a total risk corridor. Then we've carved off to the side the blueprint risk, advanced shared savings risk, and then have a total. I'd like to note that in the bottom row, one care of Vermont, we have now taken on $3.9 million of the blueprint risk plus an amount that we had previously obligated to St. Johnsbury and the RH community. So in total, one care now has about $5 million of risk on its balance sheet for 2023. Slide please. Population health management expenses. Some of the elements in here we'll discuss a little bit later on as well. So when we have fewer attributed lives, that generally means less population health management payments going out to the network. The one care budget has been designed to float essentially with attribution as attribution grew. The budget grew accordingly as it as attribution shrunk as it has this year. The expenses or payments would shrink accordingly. So we can see a number of rows that just say fewer blue cross lives that are driving the change. There are a number of other rows that say change in diva funding model. Your staff referenced this a little bit in the presentation on Wednesday. I'll speak to this a little bit more as we move through. I'll also speak to a change of the CPR program which shows up here is $596,000 change from the initial submission and speak to that and some of the dynamics underneath and then the new mental health screening initiative. $1.6 million increase. I'll also speak to that in a few moments. After listening to the presentation on Wednesday, there were some questions raised by the board about the difference between these two columns. I submitted yesterday a supplemental schedule that reconciles between these two columns a little bit more completely. What it does is takes the $29 million and compares it to the $26 million but adds back the diva money that is flowing will be flowing to providers and then also adds the amount that blue cross is committed or an estimate of the amount that blue cross is committed to providers to show that when you add all these pieces together in total providers and particularly primary care have access to even more funding than they initially did in the first submission of the budget. Happy to answer questions about that slide. We didn't incorporate it here just due to the time in crunch. I wouldn't mind interrupting just for one second. I forgot that we have a court reporter today and to remind everyone that Ms. Holland is here taking verbatim notes. Ms. Holland, if you need a break at any time before the scheduled 10 a.m., please speak up. And then for witnesses, you guys know this all so well, just speak as deliberately and slowly as possible because it's hard for a court reporter to get it all down. But thank you. Thank you for that reminder. All right. Let's shift to the next slide, please. Moving into operating costs, a couple of key changes here. Certainly the 2% admin cut, ordered by the Green Bank Care Board is going to be a factor. I'll speak to this and break it down a little bit further in a few moments. Deletion of the Blue Cross contract has a couple of elements in here. We have modified our evaluation strategies. Sarah Berry will speak to that. And then we have the opportunity to update the budget. So we do a true tip-to-tail review and make sure we can capture any updates that are now known through the passage of time. So you can see that we have reduced our operating expenses down from 15.2 to roughly 14.8 million and in doing so, complied with the 2% admin cut and also updated our budget accordingly. Next slide, please. Hospital participation fees. This was an interesting dynamic, this go-around. So as a reminder, the hospital participation fees fund both one-care operations were fully provider funded ACO and they also supplement PHM or population health management payments to providers in certain areas. So the dynamic that existed this budget cycle was that with the absence of the Blue Cross attribution, it created essentially a reduced need or reduction in the needed necessary hospital participation fees, roughly 1.6 million. The reason for this is that we aspire to deliver an aligned population health management model to providers that is agnostic of insurance coverage. So in other words, we want the exact same model in place whether it's a Medicare attributed life, an MVP attributed life, a Medicaid attributed life, etc. What that means is that in some cases, the hospital participation fees are supplementing any payments we get from the payers to get the population health management payment potential up to that aligned level. So when the Blue Cross lives came out, all of a sudden that amount that the hospitals were supplementing above what Blue Cross contributed would have been just naturally gone if we just let the cookie crumble, so to speak. So what we did through the budget process was evaluate that dynamic relative to all of the changes made and what we decided to do was to leave the hospital participation fees flat level with what was submitted last year and essentially reinvest the 1.6 million that would have otherwise been a hospital participation fee reduction back into population health management payments with a specific focus on supporting primary care. We'll speak to that quite a bit more throughout the presentation. Next slide, please. All right, we're going to shift gears a little bit and dive into some of the notable changes. These topics came up, excuse me, through the first part of the presentation. We just wanted to go a little bit deeper and discuss each of these nuances as they're quite impactful or important. First notable change, the No Blue Cross contract in 2023's business, Blue Cross declined to enter into an ACO contract with us late in December. The two important impacts for me were is that we no longer have Vermont's largest insurer contributing to the all-payer model, but perhaps more importantly it left providers with insufficient time to prepare for the financial impacts. And the group that in particular mattered to me the most were the CPR, comprehensive payment reform participants who had been relying upon a fixed payment and to learn late in December that that was no longer going to be an option, certainly left them with a number of questions about their financial circumstance rolling into 2023. As such, we engaged with our network. We started even in the week between Christmas and New Year's to convene participants within the One Care Network, in particular the CPR practices, discuss different strategies, moving forward, discuss what we knew, which was very little at that point in time, and that also led to the development of a self-funded initiative and this mental health screening initiative for primary care that we'll speak to in a little bit more depth later. Actually, right now, next slide, please. So in light of the Blue Cross news, we collaborated with the UVM Health Network to develop an ACO program between the two organizations. This is an alternative to using a third-party administrator as an intermediary that can bring in a number of self-funded plans or RISA plans in one swap. So it's a direct UVM HN health plan to One Care ACO arrangement. In terms of its design, it's very similar to other commercial programs we've had. I can't share everything in public. There's some confidential elements to this. So in summary, it looks and feels very much like other commercial ACO arrangements One Care has run in the past. There is a cost to operate this program to the hospitals of about 300,000. That comes from that exact same dynamic of supplementing the revenue streams into One Care to get up to that aligned population health management payment base. So we have the exact same financial model for the providers, regardless of whether it's a UVM HN covered life or a Medicare life. Next slide, please. Thank you. CPR. Apologies in advance is going to be a little bit complicated as it affects funds flow in an already complicated program. The Comprehensive Payment Reform or CPR program is a payer-blended fixed payment initiative for independent primary care, but operating this program since 2018. Historically, it included a Blue Cross fixed payment component. So in the absence of that component, not only did it mean that a portion of these practices revenue was going to revert back to a fee-for-service structure, it also meant the amount that One Care was supplementing on top of that fee-for-service level was essentially gone without an intervention. So we engage with the CPR practices and discuss ways to stabilize their financials, particularly as they transition from December into January and smooth that out as much as we can. We did not want any disruption for those practices. We were somewhat limited in our options, but what we ultimately decided to do was to migrate MVP attribution into the CPR financial model, even absent a fixed payment arrangement. This helped to lessen the financial drop-off for the participating practices and restore some program scope and alignment. We, in the first couple of years of this program, before Blue Cross offered a fixed payment option, we did the same thing with the Blue Cross live, essentially. And what we do is we calculate the CPR, we run the CPR math for all of the attribution, but then in our payment model, accommodate the fact that some of the payments are going to go directly from MVP to the practices in the fee-for-service structure. So on the next slide, I can show this a little bit more. When we have a fixed payment option, it means that we can redirect healthcare dollars to certain parts of the healthcare system that we think our priority primary care naturally is one of those. So the two columns on the left, FPP stands for Fixed Perspective Payment, we can allocate an increased amount of the Medicare and Medicaid fixed payment to primary care and facilitate that through the fixed payment arrangement itself. When we have a payer that does not offer a fixed payment arrangement, it affects the funds flow. We now have the light green bar on the right, which represents fee-for- service and it's an estimated amount that will be paid from MVP to those participating CPR practices. But the CPR program, though, pays more than fee-for-service. So we now have a gray box that says dues, dues is akin to participation fees that is now funded by the hospitals. So you'll see in our budget that the CPR line item has increased by about $500,000. That's a change in funds flow more than anything else. And again, I apologize for the complexity, this isn't a complex model here. But I just wanted to explain that dynamic where we really wanted to get the MVP lives back in the CPR framework, but need to do so, recognizing that fee-for-service will still fly for those particular practices. Next slide, please. Diva $2 million direct payments. This was discussed also on Wednesday, and I hope to clarify a little bit here today. When we submitted the budget last fall, we included a $2 million unsecured revenue line related to the Diva contract. We didn't really know what to call it. That was our best label. It was unclear at the time whether those funds would flow through OneCare, then to the providers, or be processed as payments directly from Diva to the OneCare participants. It ultimately is the latter. Diva will make those payments directly to the providers. This means that providers will receive some of their funds through OneCare, some from Diva for the same initiative, and all the payments are linked in some way to outcomes-based components or something that the providers need to do in addition to their ordinary day-to-day or the results they produce. So, the revised budget reflects this change. We deleted the $2 million unsecured revenue line that's revenue coming out, and also inserted expense offsets to the initiatives and components that Diva will be funding. So, you can see on the P&L income statement that there are some negative expenses, contract expenses, if you want to call them that, to reflect the money that will be coming right from Diva to the practices, but as part of the OneCare program. We direct Diva which practices to pay and when for their performance. So, it's very much integrated into the OneCare program suite. The funds flow is the change. It does not affect overall provider payment levels or amounts or the program design, just the funds flow. So, in the submission I sent in last night, it shows that as part of the reconciliation between the initial budget and the PHM payments and what we now have in our revised budget. Next slide, please. All right. Notable change number five. 2% admin cut is ordered by the Green Mountain Care Board. That amounted to approximately 304,000. Because OneCare is a fully provider funded ACO, that cut results in essentially expense savings to the hospitals, but as I said before, we kept their participation fees flat this year. Ultimately, this cut results in fewer resources to support ACO activities and the participating providers, which is a concern to me. And as we do every year, we update the budget tip to tail. There are other ups and downs in, but they net out to approximately 8,000. So, it's pretty neutral this year. In terms of the changes that we categorized under the 2% admin cut, there were five positions eliminated from the budget, totaling about 420,000, add on fringe expense savings along with those positions. Then there are other cuts, some are up, some are down, frankly, but there is a software and contracting increase or consulting rather increase. This is going to relate to our evaluation strategy that we'll come back to in a few moments. We reduced public relations, expenses, and then we updated for the Green Mountain Care Board build back. So, we had to make all these different moving parts come together to aggregate up to this 2% admin cut of 304,000. Quick pause right here as we're going to transition over to Sarah Berry, who's going to cover the evaluation strategy. Thanks, Tom. Good morning, everyone. For the record, this is Sarah Berry, Chief Operating Officer for OneCare Vermont. So, Kelly, we can go to the next slide. And in the next few minutes, I want to cover a couple of key topics that OneCare has been asked to address, including how we've evolved our evaluation strategy, a little bit about executive compensation, and then a fair amount of detail related to the benchmarking budget order and the progress that we've made working with the staff of the Green Mountain Care Board and our vendor over the last four or five months or so. So, picking up from where Tom left off, in the budget, there was an FTE originally planned for an evaluation staff member to really help us systematize and be a little bit more aggressive in evaluating the impact of some of the programs and policies that we have put in place. And based on continuing conversations that OneCare had with our board of managers through the fall, we really took a step back and decided that there was a need to kind of upscale that work. We needed to have a deeper bench of people that we could call on to do this work, and we needed to facilitate getting to some results faster. So, over the course of the winter, we engaged with our board, and our board ultimately approved a strategy where we would eliminate that one FTE position, and we would outreach and identify a consultancy or contractor who had expertise in complex evaluations such as we're doing in the healthcare reform space and could really aid us in that work. So, in that effort, we really set the goals of this evaluation work with a contractor to be focused on evaluating the effectiveness of specific OneCare programs and initiatives, those that we prioritize for this current performance year, and to use the results from those evaluative efforts to really drive decision making about population health investments, strategies, policies that we may then want to adapt as we do our planning processes and ultimately are headed for the 2024 performance year. So, the process we went through was very comprehensive. We met with many evaluation firms that have lots of expertise, and it turns out that many of them also have contracts in the state of Vermont with various entities and therefore had either real or perceived conflicts of interest. So, that took us some time to negotiate through those. We actually went pretty deep through two different rounds of conversation with different entities before identifying a third company that really could meet the timeline, had the bench strength that we were looking for, and didn't have those specified conflicts or perceived conflicts of interest. And so, I'm very happy to share that we actually signed that contract last evening. We have already had some tremendous planning work underway, and we are looking good to meet the timelines that we have set out with this company. So, the focus of this engagement for the current performance year are really around five key pieces of work here. The first is to go deep with us and design, conduct, and report on four studies of programs that we've had underway or requirements that are set forward as well by the Green Mountain Care Board. So, you'll see on the slide a focus on our comprehensive payment reform program, our care coordination program, the value-based incentive fund. This is really looking at and studying the results from last year because, as you may recall, the value-based incentive fund has now been integrated along with our care coordination program under the new population health model framework, and Dr. Wolfman will share more updates about progress and that evolution and when she speaks in a little while. And then finally, there has been an open budget order over the years for OneCare from the Green Mountain Care Board regarding examining return on investment for OneCare's activities. And so, we thought that it would make much more sense to draw on national experts who could do the literature review, really look at how to design that study, and so we've embedded that as one of the key studies that needs to be completed in this engagement. And then finally, because we are under a new population health model framework that we implemented in January of this year, we asked this company to help us proactively design the study that would need to be conducted next year to start to look back at the performance and potential changes that are happening in the system this year as a result of this initiative and policy. Next slide, please. So, with the evaluation, we are moving forward with a deeply mixed methods approach. As you can imagine, there is a lot of quantitative data that will be used. The vendor will be looking at regression-adjusted trending, benchmarking, and subgroup analysis, and we will be working over the next few weeks to start to get them the data under this arrangement so they can begin that process. And then in parallel, it's always important to understand the experience of providers and patients in the broader system of care, and so there will be focus groups and interviews conducted with key stakeholders. Those key stakeholders are defined differently and broadly for each of those substudies. Next, we really needed to think about the burden of engaging in evaluation activities on our providers and the limited time and availability they have. And so one of the things we really liked about the proposal from this vendor is that they would use an integrated approach. So while each study will have its own design and results, they will take advantage of being in presence of, say, care coordinators or primary care providers to ask questions that could draw out key information across several of those studies at once rather than coming back repeatedly and perhaps drawing on more time or pulling providers further away from patient care or other obligations that they have. So that's really what I mean by the integrated timelines and methods. And so the plan is that we will have findings from those first studies mentioned by September of 23. So that's the Value Based Incentive Fund Care Coordination and CPR, that the return on investment study findings are anticipated in the November timeframe. And that was very deliberate recognizing that this board would expect updates as part of the next budget conversation. And finally, that the design of the population health model evaluation will happen before the end of the year as well. So with that, we're very excited to get started. I think this is going to yield some really interesting results. And we expect fully that the results will be mixed, that there may be some areas of strength, and there very likely will be areas of opportunity that emerge. And that's exactly the information that our board is asking for to help direct the decision making that they need to make around where to invest, how much to invest, and whether to continue or to pivot in varied directions around some of these programs that we have been implementing to date. So I'm going to pause before I move on to benchmarking. And in the presentation by the Green Mountain Care Board staff on Wednesday, there was a reference to requesting one care respond to a question around executive compensation as part of the ACO certification process. And I believe the question was really just asking us about the direct linkage between the desire of the ACO or the necessity of the ACO to drive cost control growth and quality standards with how that relates to one cares corporate goals. So in that context, one cares board sets specific and measurable goals related to cost growth reduction and quality performance on an annual basis. And really the corporate goals are represent the focus that is intended to drive change through the tools that one care as an ACO has available to us. So for example, through the programs or the data that we provide out into our provider network, the contracts we negotiate with payers or others, as well as the priorities and focus areas that we set. So for 2023, the corporate goals, which again, the staff displayed last week or on Wednesday, so I'm not doing it again here, but those corporate goals demonstrate a strong emphasis on advancing use of data. So advancing our data platform, evaluation of programs, our key activities represented this year, that again drive decision making and advancements in our investments in our programs and in our policies. So those are really the levers that we as a network of providers have available to us. And then quality is specifically addressed through advancements in our population health model and our work in health disparities. So for us, the corporate goals represent the incremental steps and progress that we need to make as an ACO to accomplish the longer term objectives. And I think it's a nice opportunity as we continue to talk about the evolution of where our programs were in 22 into 23, as well as you'll start hearing from us over the next few months, the increase in focus for 24 and beyond. It's really a long term strategy that needs to be deployed if we're going to shift some of these deeply held levers in the healthcare system in Vermont. So with that, Kelly, if you could move forward to the first benchmarking slide. Go ahead. Thank you. So I want to pause here and thank the staff to the Green Mountain Care Board for their presentation on Wednesday. I think they covered quite a bit of detail and grounding around how the evolution from say late in 2021 through now has worked as we've worked as regulator and regulated entity to figure out how to thread the needle on creating a benchmarking process that addresses the regulatory lens as well as a provider quality driven lens of where are their opportunities to improve and how might we do that. And so I'm going to discuss both of those a little bit further today. So just briefly and as a reminder for anyone who perhaps wasn't able to listen in on Wednesday, this winter, after our last budget process, we received some updates from the Green Mountain Care Board asking for changes to the draft benchmarking reports that we had first presented in the fall. And they specifically requested that we create a new comparison group. We call this the National All ACO cohort. And then also that rather than looking at the initial report in the last fall, which looked at delivery patterns as a system compared to other high performing ACO systems demonstrating effective cost control. So looking at cost and quality underneath that, the request from the board was really to separate that out and look at each individual metric and identify possible performance in each metric rather than in that broader system lens. So in doing that work, which is reflected in the updated reporting, the vendor also pulled the latest CMS data that had become available due to timing. So wanted to note for you that that data has been refreshed. It is for 2019, 2020 and 2021. And that in that refresh, the population increased by about 10%. Kelly, if you could advance the slide, please. So the next question that seems to come up quite often as we discuss this is, what is the comparison group? And I think this is a great example of where there is a tension between regulator and provider network on what might make sense as the possible comparison group. So just to walk you through this briefly, on the top of the first row of the table, there have been questions about why one care did or did not elect to use a off-the-shelf product provided by its vendor. And the very fundamental reason is that that product, while it has the name ACO in the title, does not actually look at data specifically for ACOs. It is using the National Medicare fee for service data set. So anyone possibly in Medicare is what that product provides. And really its intent from my understanding is to provide broad signals to parties that might be interested in ACO type activities. So we identified that that was really broad Medicare population level data and wouldn't get us deep enough in providing nuances and discretion that might be necessary to support the actual engagement and improvement activities. So then, as I mentioned a moment ago, the Green Mountain Care Board requested a national all ACO cohort and that is in the new reporting that represents 513 ACOs across the country. And it represents every single possible type of ACO that might be out there. So they could be very similar to one care or in fact very different. They could have upside only arrangements. They could be primary care or skilled nursing facility only. It's really soup to nuts is what you get. And so from our perspective, that's still more closely approximates a general population estimate than it does a peer group to a one care as an ACO operating in Vermont. And so there is then a third cohort, what we call the National ACO Peer Cohort. And this is the cohort that we described back in the fall. And for transparency, we continued to include in our reporting to the Green Mountain Care Board at the end of March. It is the cohort that one care finds most helpful to think about how we can identify opportunities and drive system level change. And so I won't go through the detail in this row. Again, I will just say that this was a cohort that was independently identified by the vendor by one care as to have attributes that would seem to be reasonably similar to one care as an ACO. It does represent a much smaller peer group of 20 ACOs and together they represent about 750,000 Medicare beneficiaries. So before I move on again, I think what's critical in this place is that the questions one might ask if you're a regulator or a provider network could be a bit different here. So as a regulator, you might be asking questions about the universe of what may be possible to achieve that for me aligns with the request for independent look at metrics. On the other hand, as an ACO, we might want to know what is possible for ACOs like us. And so it arises a tension around how the data are organized and then how the data are used from those different perspectives. So I just wanted to name that. I think frankly it's a tension that we all have recognized since day one as part of this work. So moving forward, Kelly, if you could go to the next slide. This is a very detailed table. I'm not going to go through it in extreme detail. What this does is categorizes all of the data that you received in the reports at the end of March into broad swaths of are these areas of strength that providers across Vermont are achieving good results or are the areas of opportunity? The lens first and foremost is that comparison to the ACO peer cohort. But again, for transparency, you can see there are footnotes on all of the areas of strength or opportunity then aligning them to either the 90th percentile benchmark for the national cohort or the 50th percentile. So not trying to hide anything here, but again, trying to make sense of information and begin to identify how to use this to evaluate where the healthcare system in Vermont is producing high value for consumers and where there are opportunities to improve. What we've learned through this process is that frankly some of the data, some of the information is more actionable than others. That's probably not surprising to those of you who spend your life working with data. And I think it's important for those of you who maybe aren't as familiar with some of this data to really contextualize it, to recognize that the healthcare landscape both in Vermont and federally is incredibly complex and obvious causation is not going to be found simply based on comparison to benchmarks. There's a lot of nuance, there are stories, there's interpretation that then needs to go into this. Beyond that, there are plenty of studies that have demonstrated that healthcare at large is a complex adaptive system. And when you push on one component, other aspects of that system react, oftentimes unpredictably. So that calls for us to innovate, but also to be cautious and be aware about what those other impacts could be. Overall, we believe that these benchmarking data confirm that Vermont's providers are generally providing high quality and appropriate care. However, unsurprisingly, I think to all of us there are statewide challenges, particularly in the areas of ED utilization and primary care. And as we know, these are large systemic issues that many stakeholders are taking on and working to address. This is not only in the domain of the ACO, but we absolutely believe that we can and should be part of the solution to addressing the challenges in those areas. Finally, while the report itself uses color coding to indicate one care's performance against benchmarks, so if you looked at the report, you'd see some shades of green and some shades of red. It's really important to note that, again, the local system and the context matters and the interpretation. So I wanted to point out a couple of areas that depending on how you looked at this, you may interpret to be better or worse, and the directionality is not necessarily clear. So for example, you could look at the increase in home health utilization. And you could say that that is desirable if you are also looking at home health's effectiveness in reducing utilization of higher cost care settings. So if you are ensuring that through the provision of high quality home health services that individuals are not returning to the emergency department in unnecessary ways or that they are not spending more time than they need to in a skilled nursing facility. On the other hand, you may say that generally speaking, high post-acute care spend could be a desirable outcome if you look at inpatient rehabilitation and see that that's low and that outpatient skilled nursing facility and home health use are high. So again, I'm not wanting to go through every single possible data point here, but to explain that each one of these needs to be looked at through the lens of how the system of care is organized in Vermont and how the levers interplay in that delivery of care. So what I'd like to do now in the next few slides is just walk through transparently what a couple of our areas of strength and areas of opportunity look like compared to the peer and national benchmarks. So Kelly, if you could move to the next slide. So first, two areas of strength. This graph displays Medicare beneficiary per month costs from 2019 on the left through 2020 and 2021. Just to orient everyone because I will use the same colors and the same format across these slides. The green bar represents one care's performance. The orange bar represents the peer cohort that I described and that is the medium or the 50th percentile. And the blue bar on the right for each year represents the national cohort. And I will call out that in different places we do compare ourselves to different percentiles there. So in this graph what you'll see, if you look on the right for the 2021 performance year, one care is providing excellent cost outcomes relative to both the peer and the national ACO cohort. One care has costs about 8% lower than the peer cohort of 20 ACOs and just under 2% lower than that national cohort of 500 plus ACOs. Next slide please. In the second graph, we're looking at preference sensitive or outpatient sensitive preventable admissions per 100,000. This is a composite measure in the reports there. This is then broken out into 15 individual procedures, things like hip or knee replacements, hysterectomies, coronary artery bypass graphs. So all of that data is provided. And again, the graphs compare one care's median performance to the peer and the national cohorts. And what you will see, if you look at this graph as well as the underlying data, is that one care meets or exceeds the peer and national cohorts for all 15 measures when compared to the 50th percentile. And when you look at the 90th percentile, one out of every three procedures continues to be above that 90th percentile benchmark. And just as a note, recall that those are calculated now independently for each one of those procedures. So it, while it's possible, it is not likely that there is an organization out there that is exceeding in all 15 of those procedures. Next slide please. Now on to two critical areas where one care's performance is significantly below the peer and national cohorts. So unsurprisingly, as I mentioned a few moments ago, we all know that the emergency department utilization and costs are high in Vermont. And so here you see that that is a pattern across the three years being studied. And it is true both on a utilization, so on a visits per thousand basis, as well as on a cost basis. Next slide please. So unlike the prior slide where lower would be better, in this case, and these graphs looking at primary care, higher bars would be better. So the first chart is looking at how many Medicare beneficiaries had a primary care visit in the second, an annual well visit, which are defined as slightly different things and both measured in the report. And unfortunately, we see that both primary care utilization and the annual wellness visits are lower than we would like to see, and that that is consistent across all three of those performance years. So I think the question then becomes, what is one care doing about this? And if you could go to the next slide, Kelly, this is really, I think, an opportunity to pause and reflect a little bit that ultimately, as we have engaged in this process with our vendor and through conversations with the staff to the Green Mountain Care Board, it has been a useful process. There have been some confirmation, I would say, of things that we knew from earlier data, but there haven't been any dramatic surprises for us as an ACO in the data. And so when we think about those areas of opportunity I just mentioned, we actually need to look back to 2022 in one care's history and early in the winter and spring of 2022, as we were starting to look at where we needed to drive change and where we needed to incentivize that behavior, we actually identified ED utilization and reducing avoidable ED utilization and improving wellness visits as two key areas that we would incentivize in our population health model. And you will see those reflected for implementation as of January 23. And Dr. Wolfman will speak more about that work in just a moment. But broadly speaking, still sticking to the lens of how benchmarking data has informed that evolution or that focus, what we've really done in those two key areas is first to set performance targets. We did that using variation data that we had within our network. We then are gathering that data. Some of it is claims-based. Some of it requires manual data collection, depending on the measure. And we report it out to every organization that it's relevant for on a quarterly basis. And we transparently identify high and low performers and provide patient activation lists to really start to drive outreach and engagement with individuals and help to provide information about the value of preventive care, for example, or choices that could be made to avoid unnecessary utilization of the emergency department. And then what we've really focused on is different ways to disseminate that information through things like our health service area consultations, providing information about successes and best practices. And most recently, we've really been focused on a series of webinars that are calling out high performers within One Care's network, asking them to come present. What is it that they're doing? What are the workflows they have in place or the strategies that have allowed them to excel in those areas? And so you would see in the call out box in March, that peer-to-peer learning process really focused on the wellness visits, focused on three different organizations from across the state and described some of the strategies that they've put in place, such as prioritizing a culture of wellness from the moment somebody engages with the practice and say walks in the door or has a virtual visit through their engagement with their health care provider and also in follow-up. And so we are working directly with our providers through these various mechanisms to improve performance in these critical areas. And we are also engaging with other ACOs. And so one of the open questions for us to address is, okay, if we understand that there are other ACOs out there that are maximizing performance, how can One Care engage with them? Our vendor provides us with the names of those organizations, and we have been reaching out to have conversations with those high-performing organizations around a focused discussion and to ask them, you know, what are they doing differently? So without providing you necessarily the name of the specific ACO, I will tell you in a recent conversation with a high-performing ACO around reducing avoidable ED utilization, they first noted for us that this is a particularly challenging topic in rural environments, that there are constraints that are different in terms of access to services and the way those services are organized in rural settings that might be quite different than urban or suburban settings. And then they really described processes where they looked for specific drivers of EDUs. So they went deep in the data. And one of the examples they provided us is they looked at urinary tract infections and why were so many people coming to the emergency department for those UTIs? And they identified that they really had issues that they needed to address with the providers as well as with patients or with consumers of healthcare services. And so their focus from a provider lens was really on how do we standardize some protocols around how you actually effectively treat patients that might have a UTI and what setting can that be done? And then they also focused on patient education and activation information, so things like putting posters up in a primary care office to remind patients that they could call the doctor's office rather than go to the emergency department and that perhaps that could be addressed over the phone or in another facilitated process. So ultimately for us, what we identified is that there's not a brilliant, you know, kind of new intervention that needs to be put in place that there are lots of small changes that need to be made. Those changes take time and they take focused energy and they really wrap around behavioral changes, behavioral changes, and system changes for providers as well as for consumers of healthcare. So I know I've covered a lot of information. When we get there, I'd be happy to back up and answer questions. But before that, I'd like to turn it over to Dr. Wolfman to describe a little bit more about the key actions that we've been focused on through our PHM program and some of the data that we've been seeing. Dr. Wolfman, before you start, I'm getting a few notes that folks can't see your slides. I can, but I guess some folks that are in the public cannot. So I'll just point out to the public that the slides are available on our website if you go to ACO oversight and then Fiscal Year 23 and OneCare, the slides will be posted there. And for the OneCare folks, I don't know, I doubt there's anything you can do in the middle of it. I don't know if there's anyone on the technical end that can do it, but I want to interrupt this so folks can get them on the website if they're unable to see them. Thank you. Chair Foster, would you like us to stop, screen share and refresh it to see if that makes a difference? We might as well give that a try. I mean, I can see them perfectly fine. I think the board can. They must be able to. Yeah, just give it a quick try. Okay, thank you. And Chair Foster, this is Susan Barrett. They are available also under the today's board meeting materials right on our landing page for the Green Mountain Care Board website. Maybe it would be possible if people could just call out the slide number they're on so the public can follow along that way too. Great. So we just finished slide 29 and I'm now going to turn it over to Dr. Wolfman. Thank you. Thank you. Good morning. I'm Carrie Wolfman. I am the CMO at One Care Vermont. Next slide please. Thank you. So this again is slide 30. Sarah just presented what we're doing in 2023 regarding an evaluation strategy and what I would like to do right now is just pivot to a couple of slides to update you for your awareness on surveys that have taken place in 21 and 22 so that we could evaluate our work. Next slide please. I'm not going to go into lots of detail regarding the table at the left here but we put this here for your awareness. Oh, that is not the slide. There we go. Thank you. Put this here for your awareness just to show you that we have done a lot of surveying of our network over the past couple of years. We can come back to detail about some of these in the future if desired and I will be touching on a couple of these especially the one at the bottom in a future slide today. I'd like to draw your attention to the right-hand side of this slide and tell you that we did do a very small qualitative verbal survey and interview survey. This involved Dr. Jacobs who is in the family medicine department at UVM. I was involved and Dr. Congeano. We wanted to study how well faculty family medicine physicians understand value-based care work and its impact on their own work as well as an understanding of ACOs. So our target population for this small verbal survey was the academic family medicine physicians. This was again qualitative and we recorded the virtual interviews and then transcribed and coded the responses. The findings are what I really want you to pay attention to here and those were that family medicine physicians do understand value-based care. In fact, the younger and more recently trained family physicians only know really value-based care as the way to practice and all of the family medicine docs that we interviewed are looking forward to further evolving their team-based care teams and the takeaway here at the bottom is that they really do not understand ACOs. So those are the key findings of that short but very important qualitative study that we did present at the Society of Teachers of Family Medicine Conference in Savannah in September. This drew some really interesting conversation and others around the country said that they were finding the same when they interviewed their providers. Next slide please. Our value-based care team did partner last year with the Larner College of Medicine research team to develop a survey tool so that we could interview and survey our providers across the network. A literature review was done by this research team and they found no existing provider survey that we could utilize so we had to build a survey in red cap to use. The team based this on a technology acceptance model and they based it on two themes. One was ease of use and the other was perceived usefulness. So again this model really is one that evaluates how people utilize IT information technology and we applied that to how our providers utilize one care Vermont. We got a very low response rate unfortunately. It was difficult to disseminate the survey. We got a 7.6 percent completion rate and the most common response was neither agree nor disagree making us believe that perhaps there's a lack of understanding of the ACO or poor question choice. There were 25 questions on this survey. So the key findings were that for usefulness theme the usefulness theme the highest correlations were with those from those who are rewarded for good outcomes who believe they're rewarded for good outcomes those who have an ACO membership by choice and those who have a higher percent of patients in the ACO. For the ease of use theme the opposite pattern was observed. These results were considered by the research team to be valid but we also agreed that they were minimally actionable partly due to the low response rate. One of the most important or interesting findings was that independent practice respondents were more than twice as likely to report that they understand one care. So over on the right of this slide key takeaways and next steps. Respondents often lack an understanding of one care. One care remains dedicated to surveying a broad group of stakeholders to improve its work. Survey mechanics are challenging it was difficult to put this together. Balancing qualitative and quantitative analyses is optimal and we believe that we can better centralize and coordinate survey approaches and evaluations as we are planning to do this year as Sarah already shared. We will be rebooting this survey and sending it out again in June or July and what we will do this time is survey not just providers but lots of other types of members. So when we say providers loosely we mean different things. So we have clinical providers and we have providers who are part of the ACO network. We want to interview a broader range of providers to include administrative people, managers, quality managers, others who are involved with the ACO so that we have a broader feedback on the use of the ACO. Next slide please. You asked that we give you more detail and an update on our population health model so I'm going to turn to that next. Next slide please. So just to go through sort of a definition or explanation of how the population health model works for 2023. We blended the base, the care coordination payments and the bonus funding streams for purposes of promoting clarity, simplification and efficiencies this year. So this really marries care coordination and quality improvement activities. It rewards teamwork and practices and across the care continuum at the local level and it drives work on identified priority areas for both quality improvement and cost reduction. Next slide please. Again the PHM is not new. It is a blend of activities that have been going on for the past couple of years. The metrics for 2023 for the population health model are listed in this table. So there's a lot more information that was in this table originally but we tried to simplify it and I know it's a lot. I'm not going through all of the numbers here but the metrics are in the left hand column. They're basically six so the three at the bottom are all diabetes metrics separated out per payer. The third column over shows the baseline performance. The colored column is comparison performance for the first quarter and then the target is in the right hand column. So as you can see by the boxes that are green, targets are being met for basically three metrics, the child and adolescent well visits and developmental screening and the diabetes metrics across all payers. You may have some questions about this later but I'm not going to pause here and go over the particular numbers. You may have some questions about how we set the targets which we can come back to later. Next slide please. The way that we are driving improvement in these clinical areas is to work at the local level with the population health value-based care teams and what we are doing this year is rounding twice, once in the spring and once in the fall. We just finished our spring rounding which we completed thanks to a very hard working value-based care team at OneCare. We put all of these into about a five-week period and so I want to give you some results of that. We met with all 14 HSAs starting March 27th and just finished. We expanded our invitee list this year. For the first time it wasn't just hospital-based leaders that were invited to these consultations which we are also now calling conversations. We also invited leaders from independent and employed primary care, the area agencies on aging, the home health agencies, the designated agencies, blueprint hospitals, etc. There were some other entities also represented. The leaders who were invited and the audience included key executive, operational and clinical contacts. The average attendance rate was 11 leaders per consultation so that's not counting those of us from OneCare who attended. If we count everyone it was about 25 people per session who came to a virtual meeting. We did perform the first one in person at St. Johnsbury and we're hoping to go in person to many more of these for the fall rounding. At the end of each of these conversations we did do a real-time survey to analyze the content, the purpose, the information that we shared, the data, the analytics that we shared to see if it was useful to them, if we were giving them what they wanted and 94% of the respondents found that the consultations were insightful to them. Next slide please. So again this is just the first quarter. We didn't want to give you specific numbers because we can see trends but we're not going to see the real outcomes of this work till later in the year but I wanted to just tell you what some of the findings were in this initial spring rounding. Randolph is the only HSA right now meeting the initial hypertension follow-up metric. The Rutland HSA is increasing Medicaid expanded primary care engagement and at the same time lowering spend rate in that same group maybe there's a correlation maybe not but that was interesting. Springfield is increasing their primary care engagement in a meaningful way and also reducing emergency department utilization, increasing well visits. Bennington is reducing readmissions significantly. They are increasing team-based care and able to show that and also showed some interesting data on how they are increasing both the documentation and the completion of colorectal cancer screening. The Newport HSA has established daily care coordination rounding in primary care and has also shown meaningful change in their control of diabetes and St. Johnsbury is working on reducing avoidable ED visits and is meeting stretch goals not just target but stretch goals in the diabetes control metric. So it's been really meaningful conversation that we've had at these meetings where people can share the work they're doing. We have peer-to-peer sharing. We're sharing best practices. We are accumulating these takeaways so that we can then go back to them, find out what their methods are, be prepared to share that to other HSAs in the future. Next slide please. The accountabilities for our population health model are represented here for this year. So there is a required tri-annual care coordination reporting. Teams have to be willing to undergo a timely response to any audits. And as you know we incorporated care coordination requirements and accountabilities into the quality work in the population health model. So the HSA teams have to meet care coordination accountabilities to unlock any of the funds in the population health model. So the accountabilities include ongoing work with populations of focus which include these groups that are listed here. High medical and social risk, high utilizers of the emergency department, those with a high total cost of care, and those with high inpatient use or utilization. The population health teams must also engage in ongoing process improvement plans if they are not meeting these care coordination targets. So this is an ongoing process. Our teams meet with the local teams at least once a quarter, more often once a month. Next slide please. This is just a sample but I wanted you to see what we are now showing when we have these HSA level conversations. It's really the first time that we have sort of shown various organizations within an HSA how everyone is performing together. So it's it's driving a little bit of what I would call competition for the first time. So they're able to see where they stand compared to the other organizations in their HSA. They can compare that in the second row from the bottom to the one care total. And then they can see their health service area rank at the bottom. So for this particular HSA for example they might say oh we're second for the age 40 plus annual wellness visits but we are 10th when it comes to diabetes control. This information is also available on our portal for our members and there is the ability to drill down all the way to the provider level. So I can go to my own patient list and see which of my patients by name are not meeting targets. Next slide please. So as I mentioned we wanted to survey in real time whether or not these conversations and consultations were meaningful to our network. So we asked them just in real time at the end took about two minutes to answer eight questions regarding engagement and we were very pleased with the results. So on this slide it just shows that the majority of those who took the survey at the end thought that the data that we presented regarding health disparities was insightful. And by the way 155 people took the survey. I'm sorry 155 people attended and 103 took the survey so we had about a 66 percent response rate to this real time survey. So even though there was positive feedback on what we shared regarding health disparities there were comments added that they want more information in this area which is part of our plan for the fall rounding. Next slide please. When it came to how effective we as a one care team were at achieving our goal of creating a space for collaboration again the majority of people thought that this was a meaningful way to collaborate and found it helpful. They did make a comment that we need to continue working on ways to both receive request and receive their feedback. Next slide please. So related work and next steps. I have shared with you already that we will be rounding again in the fall. We are having local meetings monthly to quarterly. We are having quarterly quality webinars the first has already taken place and the second is planned for June. The first was about primary care engagement and wellness I'm sorry. Yes wellness visits and it included a solo practice and FQHC and a pediatric practice who are high performing. So they came to this webinar and presented their successes and shared their learnings. The June webinar will be about ED utilization. So we will reach out. We will find those who are highest performing when it comes to ED utilization and ask them to share their successes and their methods. We will also be reaching out to low performing participants. Those who are for example not meeting the care coordination requirements right now there are only about two practices I believe that are not meeting that but we will keep a close eye on that. We want everyone to be able to succeed. So our goals are not only to sort of share best practices from those that are doing well but to identify those who need extra help. We will supply them with IT support. We will help them utilize our patient prioritization app so they can obtain their list of patients who are not meeting the goals and work on panel management in that way. We are already involved and just about complete with establishing our 2024 metrics and our policy regarding those metrics. These will include added accountabilities which we can share with you in the future. Next slide please. So now I would like to just switch gears slightly. This is the last slide and it is regarding the notable change number seven in Tom's list of seven notable changes for this budget revision and this is information about the mental health screening initiative for primary care. One care is offering a one-time mental health screening initiative this year only of $1.6 million total that will be handed out in two different payment installments to primary care groups that are participating. The first payment is due to go out very soon I think in a couple of weeks and that will go to those practices who implement or already have a protocol to administer depression and suicide screening for patients age 12 and older and also to report those results electronically. Participants who are already screening must give us a year in 2022 baseline report electronically. Participants must document and track screening and also follow-up starting in July. We want them to document their follow-up for any positive screens and again we're requesting that this is electronic and they need to give us those reports. Qualifying primary care practices must report their progress back to us in the latter half of the year so we can prepare to pay out hopefully all of the money by the end of the year in December to those who met payment number one requirements and then who electronically report their results to us. Just to note we are not measuring their rate of improvement for this year. We want to establish a process of more complete screening for depression suicide and then documentation of follow-up. So that is the last slide I just want to say that the notable budget changes that we have presented today compel us to further support primary care and mental health care for Vermonters to further promote cost and quality accountabilities via benchmarking and evaluations and to continue providing tools and financial models that are needed by our network to deliver high quality affordable health care in the right place at the right time. Thank you for your support and for listening to our updates today and we are available for your questions. Great, thank you all very much. We'll take a break. Why don't we go take 15 minutes? We'll come back at 10-10. Okay, Miss Holland, are you all set? I'm ready. Great, okay and again if you need a break while we're going just like me. Thank you. Of course we'll go back on the record and we'll turn to board member comments and questions and we'll start with member homes. Okay, great. Thank you and I'm not sure if I'm the only one but your camera is not on for me but maybe it's fine for everybody else. There you are. Okay, great. Thank you. All right, so happy to start. Thank you so much to the ACR team for the presentation. I think there was a lot of clarity on some of the issues that we raised at the last meeting. I'm really looking forward to seeing the new vendor's evaluation results next fall. That'll be exciting, hopefully it will guide programmatic decision making in the future and be very interesting and informative for all of us to see. I have a few questions. I think the first is pretty high level but as I look at the operating expenses per attributed life you know we can see that with the loss of the blue cross blue shield lives that has risen substantially. If we look at our staff's analysis it's now higher than it was in 2020, 2021, 2022 so that's an unfortunate loss and efficiencies. So my first question really is what is your ideal or your target ratio of operating expense per attributed life and how does your ratio compare to high performing ACOs in your chosen peer group? I think a stab at that one is Tom Boris again. In terms of how it compares to other ACOs that's a great question one we haven't had time to delve in but with some of the other partnerships or discussions we're having with other ACOs I think there's opportunity there to compare or evaluate our operating expenses relative to other organizations. You know I'm thinking about this is an unfortunate dynamic that with the loss of attributed lives the same kind of infrastructure when you do that ratio just it's going to bounce up in terms of operating costs per attributed life. We thought about this quite a bit a couple dynamics I think are important to note one is one care is operating expense structure is largely fixed costs there's a couple of components that move with attribution but it's really designed to be a base upon which these ACO programs can be built and operated. The other dynamic that's important to note as well is by adding back in the self-funded contract at least from the ACO infrastructure standpoint there's a very comparable amount of work even though there are fewer attributed lives so that contract kind of backfills any operational savings that you might expect otherwise expect to occur and then the third point I think that's just important to note is that we just need a certain level of stability in our operating expense space to continue through time. Attribution will go up and down through the years add a program lose a program we need to maintain a certain level of infrastructure just to keep what we have built up and running so it is a dynamic that panned out because of the loss of attribution and we continue as always to really look closely and hard at our operating expenses in the cost born to the hospitals. I think it'd be really helpful to as you're delving more closely into what other ACOs are doing and doing this benchmarking to really get a sense of that infrastructure that fixed cost and what does that look like in other similarly you know situated ACOs and to the degree that you can share that with us that would be extremely helpful. Okay my second actually my second question is much more in the weeds but in some ways some of these questions are going to come in the order of the slides so my second question was around it was on slide 10 and I noticed you were spending about $50,000 on advertising recognizing that's down from over a hundred in your initial budget but I actually it piqued my curiosity because I'm wondering who your target audience is and what you're trying to sell or what message you're trying to share or where that who are you advertising to? I can first start with the label it's the advertising label is more of an accounting chart of accounts bucket that we put these funds into in terms of our approach through public relations it's not so much advertising or marketing for market share anything of that nature it's to really explain to the public to you folks the legislature anybody who's interested frankly and what OneCare does so it's really there to help spread the story we talked a little bit about challenging challenges getting participants and the public to understand what an ACO is so we do invest some time and energy in that work over time prior iterations of this board have asked us to do more of that and we're actually based on new instruction or guidance starting to taper that down a little through time but I do think that there's still a need to continue telling the story so that there's a greater level of understanding about what we're trying to do here as an ACO operating in Vermont so it's it's it's expenditure I mean is it I would just love to know is it you know internet advertising is marketing or is it lobbying efforts or is it advertising in in print form or what would be included in that message delivery or is it just the time it takes to you know to have PR individuals reaching out I'm just I'm trying to understand of what how that's manifesting itself in the budget sorry just pulling it up here for the the main expenses in that category include our website maintenance which is a pretty significant expense to maintain the website we have another amount from Montdigger where we post press releases or things of the like we also have expenses related to some social media platforms like LinkedIn and Twitter where we try to keep our message in the forefront for the community so it's an amalgam of a number of small expenses that add up to that particular room okay um my next question actually was about um and I may come back to some of the provider understanding of one care I think that was later in the slides so my order was a little bit in the slides here my notes but I wanted to talk a little bit about the mental health the screening and the follow-up initiative significant resources being devoted to this program you know $1.6 million and I'm wondering about the design of the program in the sense that was the program designed based on evidence that providers in your network were either one not already screening for depression and suicide risk suicide ideation or two screening but not following up I'm trying to understand what specific problem the incentive structure is trying to solve recognizing there's fully you know there was a mental health crisis but the incentives are to increase screening and increase follow-up so I'm wondering if you're finding that providers are not already doing both of those things I'm happy to take that first I agree with what you already said I agree that screening is occurring the conversations we had in our population health strategy committee around this initiative had to do with the fact that we are not able to capture the true amount of screening that is occurring for either depression or suicide electronically at this point in time it is and remains an annual quality metric but it's a manual abstract manually abstracted metric we want to drive in increase obviously in the screening but also drive a recording of the screening and a tracking method to discover where we may have a problem with lack of follow-up lack of referral and follow-up so it's a it's a multi pronged initiative more screening needs to occur certainly more suicide screening needs to occur we would like the standard screens that are being used to be recorded in digital fields so we can actually run a true report of the results and the work that's being done and then we'll have a better picture about where to drive change so it's all of those and is there any are there any steps or support that one care can provide as we increase screening and increase the need for referrals to more mental health clinicians and still face a shortage of those mental health clinicians is there anything that one care can do to help the providers in their network when they now have referrals that can't be met because of our shortage in that in that realm what happens with that well i think that answer is also multifold we are driving care coordination activities care management activities so there there's input from the blueprint for behavioral therapists support in our primary care clinics we are incentivizing the independent practices in our cpr program to integrate mental health into their primary care medical homes and not all mental health counseling behavioral therapy comes from what we think of as psychiatry primary care practitioners provide a lot of that so the follow-up can be a referral to a da it could be a referral to a private psychotherapist but it also might be a follow-up a more appropriate follow-up within the primary care home so we're incentivizing primary care to do more work also in the medical home regarding mental health care okay sounds i mean i'm really optimistic i hope this works i know it's a one-time you know program but i'm optimistic that this will make some inroads in in what we're seeing is a true crisis in our state nationally as well on slide 25 there was the benchmarking comparison with respect to per member per month medicare costs between one care and both the national acos and the peer acos and one of the things that i noticed was that the the advantage that one care of vermont or vermont has seen in its relative costs of care seems to be shrinking so that if you look at between you know 2019 and 2021 one care's pmpm spending stayed the same while both the national cohort and the aco peer cohort saw a decline in spend so i'm wondering if you have dug into that to see why our spending advantage seems to be declining thanks for the question this is sarah berry for the record we've noted it as well it's an area that we're curious about i think that you know we're challenged a little bit by the confounding impact of different states and regions responses to the covid pandemic and that is making any sort of kind of causal comparison very difficult in this space so we've noted it here we've noted it in the trend as well with the annual well visits as something that you know maybe is moving in the wrong direction what we haven't identified is a pinpoint kind of laser focused reason that just says change this one or two you know critical levers and and you'll switch the direction i think to my earlier point what we're hearing as we talk with other high performing acos around the country is that it's the it's the amalgamation it's the combination of years of many different strategies and frankly laser focus and i think that's part of what we are learning at one care is you know in the early years of the all payer model we were very focused on scale we were very focused on innovation and testing lots of different things out and the cost of that in part was a lack of simplification and focus and that's really what we as an aco are trying to drive through things like dr wolfman's description of phm so a lot more to come i think you know one of the areas we would love help in and support through the broader healthcare system is what are the key questions that this raises and you know where can one care through its role not as a you know data analytics vendor in general to the to the state but where can we in our role ask deeper questions try to understand the interplay of levers and then where we can drive impact actually that's a that's a good segue to my my follow-up question which is around you know the relatively high ed utilization the high ed costs low pc visits you know wellness visits relative to our pure acos is alarming and i the key strategy it seems to be if i understand correctly seems to be to be setting some performance targets and then sharing data sharing information with your provider network about high utilizers about best practices etc etc you know posters in in uh in practices to to address for patients but that seems like an information strategy and i guess what i'm curious about is do you believe that the root cause of high ed utilization and low pc you know primary care access is because of a lack of data or understanding or information that that's going to solve or is there some other systemic problem that needs to be addressed that information flow and data is really not going to address it so will an information based strategy actually address the root cause of you know our high ed utilization and and primary care utilization yeah thank you for that question i think it's a really important one and just to clarify we certainly do have some strategies that are focused on awareness building uh and frankly using some traditional levers and quality improvement around you know setting up some pure competition uh growing that awareness in one example that i gave earlier just to clarify we do not have any specific strategies around patient education right now that was an example from a high performance here um but to your broader question i do think this issue is much more complex it's a cultural issue in vermont around people's preferences for where they receive care it's an access issue um it's about how far people have to travel and whether they can get you know uh care providers or they can get that transportation to that site of care so in that sense i think that that we are doing a lot we are trying to focus on you know high risk high utilizing individuals and being proactive in supporting those out in the community to identify specific opportunities so you know this story might be a couple years old but one i recall from a primary care provider um in franklin county was that she was shocked to learn she had a patient that had visited the ed 53 times that year and when they got to the root cause of what was going on it was food insecurity right so those things matter and our job is to use that data to drive that awareness and the opportunity both at that individual interaction right between a patient or a consumer of health care services and their health care team as well as to think more broadly in the system of care and so in that broader system you know we're really looking as an aco for opportunities to partner and collaborate with others because this is it's the challenge of our lifetime i think to really turn the dial and focus more on prevention and making sure that those social supports are in place and uh therefore driving you know utilization to appropriate settings and hopefully cost down with it could i just tag on to that this is carry wolfman um exactly what you said sarah and also um through our care management care coordination program we are using patient prioritization information in lists basically run lists um to identify those who are high eduisers um and so for example the rate of that population that had care management in 21 was 14.8 percent and in 22 it went up to 16.4 percent so if we can ramp up the care coordination services that we can inspire and offer to individuals who are overusing the ed who are admitted to the hospital too frequently who cost a lot then we can hone in on their needs and then if we also overlay that with the information we can provide on health disparities we can do even more identification of those who need extra services. So Dr. Wolfman what would be your target proportion of high utilizers that are in a care management so it went from 14 to 16 at what level do you think we'd actually see significant change in utilization what percentage of the that population should be in a care management program and how do we get there? That is a great question i don't have a set number in my mind more is better what we're doing now instead of setting a target you know we used to have oh let's care manage 15 percent of the high and very high risk patients what we are requiring now is just show rate of improvement of manage care managing these different categories these populations of focus we call them ideally 100 percent you know if you want to be idealistic but in reality you know if we can go from 16.4 percent you know up to 25 percent that would make a huge impact not only on the care for those people but the cost to the system. So and maybe this is my next follow-up question i know you have this accountability and when practices don't reach those targets around some of those issues around utilization of eds and other sorts of metrics and that you had a slide on there was a requirement to engage in a performance improvement plan and i think what i heard you say that there were only two is that is that right that you said only two practices were at that level so does that if that's right is that right i guess i should ask there's only two practices that are actually in the stage of having to do performance improvement plans because of their it's i did say that and i may have not said it in a way to be understood but those there are a couple that have not complied with the reporting that is required at this stage in the game it's not that only two are not meeting metrics that we have set in place so we have to bring them along they have to thought they have to be engaged in care management they have to meet our requirements and hopefully by holding them accountable to that they will then be performing the work in the field that we need to see happen to improve these numbers so yeah so what proportion of practices are not meeting standards then would you say what i know is that right now i can't specifically tell you for the ed metric but for the six metrics in the population health model only about 47 percent are meeting the targets in quarter one so quarter two hopefully you know more well and by the end of the year hopefully most got it all right i love your optimism i will share your optimism really interesting this is all very interesting to me um i guess my lap my sort of my and i'm really people go because i know i've been asking a lot of questions but i the provider survey results were a bit disheartening you know the very very low response rate um i think it's also you know this maybe this goes back to the messaging but it is concerning that providers don't have an understanding about one care and what you know what you're trying to achieve and i'm wondering it seemed like it was the results of the usefulness were correlated with whether the provider was an acl member by choice also correlated with whether the provider was an independent or a hospital employed provider so i'm wondering what specific strategies you are undertaking to ensure that hospital employed providers specifically you know on the ground boots on the ground understand the goals of of one care understand are responding to the financial incentives that you're putting in place responding to the programming efforts it's trickling down is it getting to the providers boots on the ground so wondering what strategies you're you're taking to do that this is sarah i can address that a little bit as we've alluded to in a couple of points throughout this discussion we are working on ways to systematically increase provider accountabilities for being in the aco and we recognize we need to do that along a pathway or a trajectory because those that maybe are underperforming we can't necessarily expect to go from zero to a hundred all at once but what we're working towards are some expectations that will go out in contracts this summer around provider accountabilities this will be part of that strategic planning process and so i don't want to get ahead of the details but within that space we're definitely considering you know are there some simple cost effective strategies where key messages about the importance of value-based care the and how it can drive improved outcomes for patients can get to individual providers so really trying to think about that and think about the fact that you know we've got that 5000 providers it's not as easy as you know an email blast for example people aren't necessarily going to respond to that so really trying to find simple inexpensive impactful ways to spread the message and if i can answer that in the finance space what we're trying to do in reporting space as well is when we have performance outcomes and evaluation going down to the practice site level rather than staying at the 10 level so in other words a hospital that may have you know five primary care sites we report on their population health outcomes and make payments it's indicated that this was for this specific practice site and maybe this one is meeting the metrics but this one over here isn't and providing more information to these hospitals that would help them dig in a little bit further rather than having just one aggregate result okay great thank you i will turn it back over to you to chair thank you very much we'll go to dr murman next hey i just want to make sure you guys can hear me sometimes when i use my good headphones it doesn't work well i um thanks everyone for the presentations i feel like i uh i feel like i really got a pretty good understanding of of what's been going on with the budget resubmission and what your activities have been recently and where things are going and i really appreciate um all the presentations today uh you know i i appreciate vicki's comments you know best care right time right place actually even like carry's subtle variation on that which is high quality affordable health care in the right place at the right time and i i think we kind of all are on the same page in agreement and i think it's a really nice basis to sort of frame frame this broader conversation um just real quick actually on the the prior topic uh that that jess had just brought up i just want to throw in my two cents on this which is i think for a um a hospital employed provider someone like myself um we don't really know what one care is but i don't know if that's a problem as long as the hospital is aligned with one care whether or not as a provider i'm being encouraged or incentivized to do specific things because of it being a one care priority or an organizational priority i think matters a little less and and i would say my colleagues like friends from residency or if through the years that work in fee for service groups that you know that are private practice groups they know what each payer pays they know what every all the rvs that are generated from from various things because that that affects their day-to-day lives and i can see that much more in an independent practice where an independent practice would be much more attuned to one care's incentives versus say like a hospital-based practice as long as the hospital organizational structure is aligned you know you're working with them and aligning them to me it's not surprising that they you know or an fqhc for instance would would know the specific one care role in um in why they're doing what they're doing and why they're being incentivized in a certain way i i don't know if anybody wants to comment on that but that's just sort of a reflection from the last conversation i will comment since i'm a primary care provider that is hospital employed i would agree with what you just said what i think is more important is that i know what the quality metrics are that we're striving to attain across the hsa and i think it is more important that leaders from the hospital the independent primary care practices and all those other continuum of care partners work together on the metrics that we've established whether they know that those metrics are coming from the aco or not is not as important to me as teamwork and trying to to work on the same things together at the same time yeah um so i i too took lots of lots of notes and and so they're somewhat slide oriented and tom went first and so i just want to sort of comment on a few things which is i really appreciate the the hard work that you you and your team and your organization have put into trying to stabilize the cpr payments we hear over and over again at the primary care advisory group and and other contexts the importance of the cpr payments to independent primary care practice care practices specifically and to try to also bring in a makeup for the gap from blue cross bush shield leaving one care with self-insured plans to try to get more attributed patients in the value-based payment program so i just want to really acknowledge that i'm sure that was sort of a lot of complex work over a holiday period of time in january when there's a lot of other moving pieces so i think that that um i i think the board really appreciates those things um i also want to sort of call out calling out um and the importance uh that was on on calling out high performing organizations within the one care network and learning from those organizations and i think that that is a really great way to leverage the size of the network um that that one care has um uh and so i just i think that's really important and and i i i kind of think that we could even expand on that tom are you going to say something no no sorry um i think you know even expanding on that i think of uh you know myself as an emergency provider um you know trying to understand since since ed utilization and cost is sort of the you know sitting out there as as an area of improvement for the one care network for vermont for a region for our country um that trying to also try to dive down uh in a more granular analysis of why those costs are high in certain asia say is it that the utilization is high is it the cost per patient is high is it there's you know more testing than other areas and trying to identify high performing organizations and and and learn from them so i really appreciate that approach of of doing that um i also i'm all appreciation here so i also appreciate the uh i have some questions too i also appreciate the uh the sarah i mean you mentioned the developing a prospective analysis for care coordination effort cpr programs r y and value-based funds i think that that's a really important thing to then track over time and and just to analyze and to figure out how we can improve our system so i think that's a a really strong effort um i do want to talk a little bit about and ask some questions about utilization or maybe i don't know if i'm asking questions or giving my opinion more but my question i guess is and i i'm trying to think i've been trying to think about this a lot over the years is um why people come to the emergency department and if we're talking about high utilization i think we really need to think about this in detail and maybe having some other forum to talk about this as opposed to a budget hearing is appropriate but um the uh i think it's helpful to use a database approach and talk with your peers and see this you know certain element of uti diagnosis groups as a utilization area that could be reduced but i also think that there are all of us who who work in emergency departments who meet people every day who come to the ed for various conditions ed directors and then ideally patient groups but those i think are much more complicated to try to come up with uh representative patient focus groups but i think ed providers would be very interested to engage in this conversation um two little anecdotes i i've had to uh get uh x-rays for my children twice over the last six weeks at hours and i look to see where can i go other the emergency department and i live in central vermont and at 5 15 p.m the option was go to to chitlin county and at 7 a.m trying to get in that ankle x-ray because she won't walk on it before school and a day of meetings uh it's chitlin county and at 6 30 p.m last night i saw a nice kid who broke his finger and mom knew he broke his finger and needed an x-ray and a splint and so the only option is to come to the er so um there's a lot of reasons um but the monday through friday nine to five makes up about a quarter of the hours of the week and the emergency department is open all of the hours of the week so i i think starting to think about i think access is a really big component of it but i think having some focus groups with ed providers i think you could get a lot uh a lot of understanding of the problem and then sort of try to work through um reducing the the cost of that um so this carry on slide 39 i think that was you who brought up this uh pretty interesting uh detailed chart of i think an organization's level of data and where they sit um and and and i guess the question that i had for you in this is do you have any idea of of how much this data is being accessed individual level organizational level and do you think it's it's worth people spending a lot of time accessing it yes to the latter question i definitely think it's worth it i think we're seeing access go up over time i don't know the percent um and tom may somebody else may know more than i do but this has only been available for a short while this particular type of grid so that people can see it um and from what i've been told by the value-based care team the access is going up i think people like to see how they stand in comparison to others they cannot go into our portal and see how they stand um directly related to other hsa practices like i can't see how my brand and practice compares to one of the primary care practices down to the little you know small numbers um the specific numbers um in this portal but i can compare myself across my own hsa at this point in time we may be expanding that for the future and i guess i i agree with you it looks like very useful information and i can see tom walsh on the corner of my screen uh and and remembering the a1c uh data point on there which i know is something that he's expressed a lot of interest as an example of something like this is there a role do you think to try to incentivize providers to look at these and and then i guess subsequently try to move where they stand in a positive way absolutely i don't know about incentivizing them monetarily although that's not a bad idea i think that is kind of folded into our population health model and when our team goes to meet the boots on the ground workers regarding these metrics they bring up the app they bring up the patient list they bring up things like this grid and they show it to their peers so they let pierce see it they discuss it jody just went to rutlin and did this um and everybody would she had 25 people at a meeting looking at this kind of information and talking about it together that was last week so that's what we want to incentivize and on the finance side um the program has a base payment component and then a bonus payment linked to those specific outcomes and for us q1 was a reporting only quarter we paid everybody the optimum amount but starting in q2 we adjusted payment levels to practices to based on that performance their specific performance in those domains and what i hope happens and i think it's starting to happen now is that calls the providers to you know connect with us and say i'd like to understand more about why i didn't meet these measures and then we can meet them in that space and hopefully provide useful information or connections or insights so that they can raise the bar and get up and ultimately earn their maximum potential so i guess tom that brings back the question of hospital based providers or like large organization providers versus independent providers and the layers of separation do you think that that still reaches or impacts the the larger provider groups in a similar way as it would in the smaller provider groups i think the smaller independent providers are just naturally by their dual role as a business leader and a healthcare provider are going to know it the the most and the deepest and the best of anybody i agree with your point before that the organizational alignment between one care and a hospital's goals is really critical and how they operate down below that i think is it's where it is a little bit tougher for one care i think you know as i mentioned before breaking down the reporting into site level information would help hospital leaders do their work and if one care and the hospitals are aligned in these priority areas and they have good information to go you know do their good work to intervene if necessary it'll be helpful um but it has been a challenging area to really get the one care concepts to flow through these hospital organizations all the way down to the provider level i was going to say i think that it's almost as if you know for a larger organization you're you're like a consulting data provider for them and i guess the question is do they want that consultation and how do you encourage them to want that consultation because it's probably the right information to get i i don't know that's a yeah a nuanced conversation i guess i can certainly say you know at the board level when there are conversations about investments in data it's very clear that those other you know medium to larger size organizations recognize that the aligned approach is more efficient and that they might not have the resources either direct money or staffing to invest in building that separately i think the challenge that we've seen just adding layers of complexity is with workforce turnover challenges in particular at the last couple years some of the long-standing relationships we might have had in some of those areas with finance or with quality for example there have been change and we're re-establishing those relationships and then trying to support how they receive tools from one care that then they don't have to reminipulate or analyze further but they can take and pivot to their provider-based groups that they already have set up so that maybe one cares at that table maybe we're at the table with the administrators and they with their their providers but either way we're there to serve and support them with that information that is ultimately most important to make it actionable and digestible otherwise you know nobody's got time to move on it and in the 2024 metrics that are on the table there is an attestation metric for aligning with the goals of the ACO so you want to be a member you will attest and align with these goals so we're hoping that will drive more interest in knowing what the metrics are and working with us on those even if the practice is hospital-owned. I have an awkward pivot to a topic that I think is kind of a challenging topic to discuss which is the executive compensation bonuses which is sort of talking with you all about your bonus salary structures and I am aware of sort of the sort of awkward nature of this conversation with you here. My interest in this topic really aligns around a lot of the similar things that we've been talking about which is sort of the power of incentives in moving the goalposts and trying to improve our our health care system you know looking back through one care Vermont budget submissions that I have seen is that the executive compensation bonuses have been paid out at 100% or near 100% through most of the years which you know reviewing the the rule from the Green Mountain care board and I think the idea of bonus compensation is that you know that that at least the incentive compensation that I've had through the years that it that's sort of a really actually high. The care board rule does not address this care board rule addresses specific immeasurable goals towards either reducing cost or improving quality. My personal experience is that 100% is almost never achievable in bonus compensation but it all depends on how you define the compensation and I don't think actually that's really the conversation today but looking through the bonus compensation goals and measures they to me don't seem particularly specific and the measurements are vague definitely compared to the specific measurements that we I think look to have our provider organizations within one care achieve and also sort of and also not very specific compared to a lot of the data that I think we now have available through this reporting tools from either your comparisons to other organizations or internally and I guess in those I would refer to like slide 35 where Kerry presented the slides where we have a baseline performance and comparison performance and target to me these are specific and measurable you know slides I wrote down some more here in 24, 25, 26, 27, 28 that Sarah presented from that survey which show you know in slide 20 sorry slide starting slide 25 actually 24 as well but slide 25 where the one care network has a far lower Medicare cost per patient per month compared to peer ACO groups I think these things are complicated because again we talk a lot about is what is the impact of one care here what is Vermont what is our you know and then but but the same time I think you know these are opportunities to measure things and and attach you know loft goal compensation that's reasonable reducing emergency department visits that seems to me to be a specific and measurable goal that could improve quality and reduce cost that could be tied to executive compensation it doesn't have you know and and there's lots of ways to do it you could compare to your percentage compared to peer groups you could look at your overall percentage you could look at cost there's a lot of things that are out of your control in that but there's a lot of things that I think ideally in the conception of what one care could be could be influenced by one care so I don't have any specific I think out recommendations but I I do reading through these goals that are that the executive compensation is based upon feel that they really could be stronger towards the measurements of the goals of one care and I even just considering you know the concept of unlocking funds and care coordination we we put the similar you know we're you you're using it within the activities of one care I think it would be reasonable to use it within the executive compensation of one care Dr. Merman could I reflect a little bit absolutely you share so this is Sarah Berry for the record I think there are many threads that we could pull on and explore a little bit in what you just reflected on one historical point of clarification I'd like to start with is you were mentioning looking back into prior budget cycles and just to be clear in the documentation we submitted every year there is a decision about what a decision outside of one care is control I should say about what the components are that will be considered for for variable pay so in the past for example depending on the level of leadership an individual's performance goal is a portion of that formula corporate goal might be a portion of it a it just so happens that in 2023 it's a hundred percent related to corporate goals which I don't do think simplifies things a little bit particularly for a public understanding of where those focus areas are in terms of the opportunity to make them more specific and more outcomes focused I think this is something that our board to recognized and reflected on in the late fall when they were setting corporate goals and thinking about the trajectory of where they should evolve and for us some of this is kind of the perfect storm of timing I'll just remind you like the benchmarking reports weren't available some of the new surveys that Dr. Wolfman spoke of we hadn't you know designed or implemented yet so I actually feel like we have put some really strong and effective tools in place that can help us measure that performance and I think it is reasonable that as we move into the next cycle that our board will continue to explore kind of increasing the accountability that one care as an entity is responsible for and its executives through that variable pay in line with how we're increasing accountabilities for our provider network and I can I can appreciate that I think that you know like we as we talked about in December the challenge of having and the complexities of having performance evaluation for an organization a unique organization like one care so thank you for that comment that was my last comment so I I would like to pass the pond thank you remember lunch thank you it's nice to see everyone um so I had a couple of specific questions my first question around the evaluations that are in line for this fall I was wondering if you could expand a little bit on why you chose to evaluate the VBIF fund given the recent change where that's getting rolled in and what we might hope to learn that will be usable for future design. Thank you for that question this is Sarah Berry um for us it was a fairly obvious selection because as Dr. Wolfman described in the evolution of the PHM model we're really integrating our care coordination and our quality programs and some of the metrics in the VBIF for 2022 were held consistent as we move into the new year and so we thought that it would be helpful to have a robust kind of outsider objective look at how that foundational year may or may not have had an impact and that throughout this process and one of the things I maybe failed to mention earlier is the reason that we have this contractor also helping us design the evaluation of our PHM model is that as they develop insights from each of these separate studies we've said tell us as you learn them so if there are changes we can make now if there's something new we need to collect or adjust let's pivot and put that in place so that we have that information moving forward so all of it very much kind of in the spirit of continual learning and improvement and we are very well primed as a team at one care that some of the results might be great and some of them might be terrible right like that that is to be expected when we are doing new things in this space but the goal is to inform how we get better and how we invest or make changes in those investments. Thank you that was helpful. When you were talking about the value-based care team meetings in the local HSAs you talked about how you've expanded the participant list to many different many different folks from the community partners I was wondering if you've looked at how that invite list sort of compares to the blueprint community health teams in those areas and what kind of overlap there may or may not be. I can take that one Robin. We invited blueprint leaders to come to the meetings so that's how we dealt with that. We did our best to identify we asked a lot of questions sent out emails to all the HSAs saying who should come and we said multiple times during each conversation if you know someone who isn't here that should be here please invite them and we got feedback that more people need to be invited but blueprint is definitely invited and did participate. Great I would just have assumed that some of the leaders from for example the DAs in the home health agencies may also have a seat on the community health team potentially or a person on those teams so I was just curious about that. On the mental health screening proposal I wonder if you could speak a little bit about how you see this fitting in or not fitting in with the blueprints legislative proposal to add dollars to support mental health integration and screening in practices. I think it aligns nicely. I don't know at this point how some of the efforts might overlap. I think that remains to be seen. I think all of us in healthcare work hard not to duplicate efforts and I do see across the state more and more partnering between all the community health team members blueprint included so I think this will be collaborative and hopefully it will create exponential improvements in our screening as well as our referrals to treatment. Okay thank you and I think actually between Dave and Jeff's they've hit on my other questions so I'll be short and sweet thank you. Great. Member Walsh. Thank you chair. Good morning everyone. Thanks for coming in and presenting. There are a lot of good things I think I want to be shorted to acknowledge those and talk a little bit about them. The simplification and focus that Ms. Barry spoke of I think is is an important thing. The evaluations plan for the CPR program, the care coordination, BBI, and the mental health initiative all really good things. Those are the types of things that we see in high performing ACOs from around the country. I think Dr. Wolfman, the slide 39 that Dave mentioned where providers can drill down into their HSA, their facility, and their own performance. I thought that that was an excellent example of how quality improvement actually gets done and how you address outlier findings in healthcare. I wonder I wondered there specifically whether the comparison was within the facility. Are you just comparing providers to other providers in that facility or are they compared to the peer network or ACOs overall? Where's the comparison in those in office but in office feedback? I think what you're asking is would I as a provider in Brandon be able to compare myself to a similar provider at another HSA in a practice? That is not something that we can do yet on the portal. It is within the HSA. However, what I can see there as you noticed at the bottom of that slide is where I rank across the HCA's. I can see if I'm number 10 out of 14 with diabetes control, that should be a signal to me that I should focus. I should get that patient list. I should run the list. I should have my team work on it. I think we will advance to where there's more and more and more transparency. This is a big first step. It's great. As a provider in an organization, I'd like to know where I rank among my peers in my hallway, but also how my organization ranks and then how the ACO, the group, the overarching enterprise ranks. That comes up in the benchmarking report too. There's tension as Sarah pointed out with comparisons. The example, I make fun of myself. I used to like to do running and cycling races. I could occasionally win my age group and get a certificate for a free cupcake someplace and feel really good that I won my age group. I finished 10 minutes behind the winner of the Women's 60 to 69 group. The comparisons matter. As a high performing system, you want to seek out the highest performance. There is, of course, a tension that if you're constantly comparing yourself to the best and you come up short, you get discouraged, burnt out, and give up. Part of the work of an organization that is supporting quality improvement is to maintain that tension. There's always a drive for improvement without the burnout and giving up. It's hard work, but having the courage to really assess what is top performing is an important part. I also wanted to acknowledge the work you all did during the holidays and in the winter to stabilize the CPR payments. That was a difficult time, I'm sure, and you did it. That's a good thing. Along with the benchmarking reports and how you perform, you talked about some initiatives, the peer-to-peer learning, some different things. I'm wondering what you consider your number one priority for the next couple of years. I have six number ones. That's hard. I guess if I were trying to find the right level of which to answer that question, for me, it's that we are driving performance and outcomes through our PHM program and that we recognize that the specific targets for measures and measures themselves can and will vary over time as we shift the spotlight based on improvement happening in our network. Ultimately, back to the earlier point about simplification and focus, that's really our belief in how we're going to effectuate change. We're steering the ship around that. You mentioned there are six number ones. I understand that feeling. At the same time, the simplification and focus. We're in a period for this particular ACO where there's declining enrollment. The future is a bit uncertain, and so trying to figure out what is the key role? Is it a pass-through organization that takes money from the federal government and distributes it across the network? That could be a primary role, and there's probably a budget that's the right size for that. There could be a primary role of conducting benchmark analyses and helping organizations improve and a budget that reflects that. They could be very different budgets. I think what we're tasked with at the moment as the care board, whether we liked it or not, or whether we thought we'd be doing it when we signed up for the care board, we have a lens of this fiscal responsibility that we have to keep in mind. I want to ask a little bit more about the enrollment. In an early slide, I think it was slide four, but I'm not exactly sure. The estimates for Medicaid attribution were rising significantly, but we know that across the country Medicaid is unwinding, and so I would expect Medicaid numbers not to rise but to decline, and so I'd like to understand how you arrived at your numbers. Sure thing. I could take that one. These are the attribution numbers that were delivered to OneCare from Diva. I think Diva is a good source of information about the general trends and patterns of their covered lives, and it's a formulaic approach, essentially, that delivers the attribution to OneCare Vermont. Around the decline, what we do expect to experience throughout the performance year is that as the Medicaid redetermination process begins, we expect to see higher than typical attribution attrition throughout the year. As certain Medicaid-covered lives are essentially exempted from the program and pick up a different insurance, hopefully, we should see our attribution count decay throughout the year. It always does, but I think the rate of decay will be more aggressive once redetermination begins. Yeah, so I think that's the correct read on the national situation. And in some estimates, that reattribution could lead to a substantial loss, the substantial number of people who lose their coverage in the order of 20 to 30%. I don't know what percentage of patients or people with Medicaid in Vermont are currently attributed, and if those that are attributed, if the decay would be the same, we're making a lot of assumptions, but a 30% loss would be very substantial. I hope that it's not that much. I hope not that many people lose their coverage, and I'd like people who have that coverage to be attributed, but it looks like it could be substantial. And so we'll put a pin in it for our staff to try to connect with DBA, but I think it's important that we try to understand that together with you. So the declining enrollment with the Blue Cross Blue Shield withdrawal, the unwind Medicaid unwinding, trying to determine a budget that best reflects the primary role of the ACO, I think is what our meeting today is about. And so I'm trying to reflect on that and to think about what budget items are fixed and what are variable. And Tom spoke about that earlier that, of course, there's a high proportion of fixed cost. And there's an old economics joke, right? Everything is variable if your time horizon is long enough. But so what we're dealing with is trying to figure out what's fixed and variable in our time horizon over the next couple of years, and what makes a fiscally responsible budget given the declining enrollment and the primary function or functions. And I'm so I'm struggling with the reduction in the budget that reflects the 2% that the board ordered in the winter, but doesn't seem to shift much with the 30% decline in enrollment, roughly 30% with Blue Cross Blue Shield. So I don't feel that that's been addressed directly so far. So if someone would like to address that for me to help me think about it, I'd appreciate it. Sure, I'd be happy to start and I'm sure my colleagues will weigh in. But I think the fixed cost point is very important because there are functions any ACO needs to have in order to operate. And whether you look at it as one fewer payer contract or X number of attributed lives, the reality is there's a bucket of work. And so I still need people who can collect the monthly required data to submit to all of our payers on which providers are signed to which organizations and make sure that's flowing. I still need people to negotiate every payer and vendor contract and participant contract that's out there. We still must operate a help desk and a customer service line, a grievance process, a compliance process. So when I think about this, what I actually go back and reflect upon is where we were in our investments in terms of technology contracts, et cetera, and our staffing just prior to the pandemic. And from a very high level, what sticks in my mind is that we had a budget approved by this board for 80 FTEs. And that was a growth phase. So we were growing. I'd have to go back and check the exact number, but say maybe by 10 FTEs at that time. We now have 47 FTEs. We're about as small as we can get to still make all of our operations work. And our team are incredibly talented and overworked every single day, to be frank. There is not a person on our team who isn't, you know, as is your staff putting in many, many, many extra hours all of the time. So that's the component that says to me it is always our responsibility to look for efficiencies to reduce duplications. And we will continue to do that. It's our obligation to Vermonters. And I don't think there's a lot there at this point in time that will allow us to continue to deliver what we need to to the state of Vermont to our provider network. And as we've been talking about on the theme today, to keep focused and improve. But that's my perspective. But I'd invite Kerry or Tom to add anything I might have missed. I think you said it well, Sarah. I think you said it well. Okay. Well, thank you for sharing your thoughts. And it's not a fun question. And I just I'll pass it back to the chair. But just before that, I want I do want to close with an acknowledgement of the analytic work and the work that you're doing with clinics. That's exactly the type of thing that we look for in high performing ACOs across the country. So I think I'd like to commend you for that work. And back to you, Chair. Thank you. Why don't we just take a quick five minute break to give a little breather, then I'll do I have a few questions. We'll do healthcare advocate public comments. We'll come back at 1120. Thank you all for the presentation. I don't have a whole lot. But before I ask my questions, I'll just preface it by saying that one of my focuses as a here at the careboard is on affordability. And we're really looking for a lot of organizations to look hard at themselves to where they can find savings, because there's only so many places we can get them for for for matters. And second, performance improvement, right? There's only two ways we can really improve our healthcare system for people. And that's performance and frankly affordability. So we are asking I am asking everybody to really try hard in that effort. And your presentation, it was great. I think it was really well laid out and helpful. I took away that you have a focus on primary care and mental health, which I really appreciated and think are two very critical areas to focus on. And it slides 29 and 42. I appreciate you describing what one care is planning to do to address some of those issues. And some where the performance targets, sharing those targets, learning from each other and those things. My question is whether you think those are sufficient to move the needle on those key areas? This is Sarah. I'd be happy to start. I think that, yes, we will start to see the needle move. But I think to your broader point, Chair Foster, about affordability, this is a big complicated topic to tackle. And so it's going to take collective efforts from lots of organizations, the ACO is one, and it's going to take time. And so I think from our lens as an ACO, what we're really focused on is making sure that we are spotlighting our incentives and our supports for our organizations in a consistent manner, that it's action-oriented, and that we are continuing that path to set higher and higher accountabilities over time. So that we could expect a tipping point somewhere down the road, where we really are maximizing the quality outcomes that we're looking for as well as the cost management. I don't think we're there yet, and I don't think we'll be there in a year or even two. But I think long-term commitment to healthcare reform will allow us to get there as a state, the ACO being part of that. I agree. It will be collective efforts and time, for sure. My question is really focused today just on, are the incentives that OneCare has the best that they think they can do for these issues? And what I'm getting at a little bit is, are the financial levers and incentives sufficient? Is the sharing of the information sufficient? Or is there anything else, in your opinion, OneCare can do to ramp up the performance on some of these? I would like to add something that Tom touched on, which is, there's a fine balance between what we're demanding and breaking point for people who already feel overworked. And so, what I think will help bridge that is meeting with people where they are, going to their location, building relationships, seeing what they're doing, boots on the ground, and getting buy-in. And when we had a conversation last week with another high-performing ACO, that's exactly what they said. That's how they're reducing ED utilization. They need to go where the work is being done and support people, both with the data and analytics, but also in a way that says, we're in this together and we want to be inspirational and not just demanding. In the finance space, I was going to mention that, I don't think we're where we need to be, ultimately yet, but I do think that we're on the right track. And specifically, we have a mix of what is essentially a base payment to providers than an amount that is connected to outcomes and bonuses through time. I think we need to adjust that line and do so in a way that doesn't pull the financial rug out from under the providers because I do know they rely on these payments, but enhance the focus on the outcomes and the accountabilities that we expect and align the financial incentives accordingly. And I think and hope that that will help us raise the bar on many of those measures. Thank you for that. That's sort of what I was getting at. Are the financial inducements beneficial enough because a lot of these providers are struggling with burden and is the money good enough to drive the change and make it worthwhile for them? It's a great question, a really great question. It's also a tension point in the one care budget and we have limited resources and means. We often hear from our network of providers that the work it takes of them to deliver on these outcomes or fill these programs actually costs them more in some ways to do that, but we try as best we can to provide those financial resources to evolve the system to one that thinks about outcomes and results more than they did when it was a disaggregated fee for service system. Right, so when I looked at that slide, I think it was 28 primary care, which is a big focus for myself personally. I know on many other board members and yourselves, I've heard it a number of times. Slide 28, we're compared to the 50th percentile. I'll start by saying I don't think 50th percentile is our goal here in the state. We want to be better than that by quite a bit and yet we are lagging significantly on primary care visits and annual wellness visits from even the 50th percentile. So when I read that, we're not where we need to be and the performance in our ACO network is actually sliding and going backwards a little bit. So we were 12.8 percent or 14 percent behind and now we're 16, 15. So it's going the wrong direction and we're really low to start. So I guess my challenge or question is that we need to make sure we're looking at this budget to fix this. And I get it. I forget who said it, but you're right. It's not just the ACO, but there is a role for the ACO and the bigger the role is for the ACO, the better, I think. So I think it's important to look at what we're doing financially for these providers so that these numbers are not going this way. On that, on slide nine, I think you've had some of the dollars that Mr. Boris was alluding to. I think it's 9.7 million and 1.5 million for the PHM for primary care, I think. I'll expand to say a significant portion of these population health management payments find their way to primary care either as the base payments or through the CPR program or as incentives. Right. As to these two numbers, 9.7 to the 1.5, I guess one thing I want to understand is when you make the payment, if it goes back to a hospital for their primary care providers, how do we assure that it's being used for primary care provider initiatives by that organization? It's a great question. Certainly a challenging dynamic for us at one care where our authority effectively ends at the 10 level once we make that payment. What one of the strategies is through communication and also communication on the payment statements to really make it clear that this payment is for the purposes of primary care support or care coordination, things like that to help direct the funds to the correct part of the organization. But that is ultimately the responsibility of the organization to use the funds in the appropriate spirit. So the best source for us to ensure that this money is actually supporting primary care in its entirety is the hospitals themselves. Yes. Dr. Merman asked a little bit about executive compensation and one of the comments I heard, sorry, go ahead, Dave, I see your hands up. Oh, sorry, this is actually just a question on the last question, which is, so is there a mechanism to track payments that go, once they go to a tax ID number that you can then track where they go from there? Or is that basically not trackable once they go to the hospital? It's not trackable for us unless we were to ask for specific reporting. And I guess at this point you have not asked for that specific reporting? We haven't. It's been, you know, I try to make sure that the payments are clear and suggest where the funds go, but I also recognize each of the hospitals are structured a little bit differently. Some have centralized infrastructure to manage a lot of this work, and that might actually be the appropriate space for some of the funds to go while another hospital has a different infrastructure. So all of our programs are designed to accommodate just the differences of our provider network, and that's why we've been a little bit less prescriptive in this space. Thanks. And do you have a breakdown of how much money this, in these two buckets we're talking about goes to independent practices versus hospital-based versus FQHC? We do have that information, and I believe, I remember correctly, it was included in the supplemental information I sent over last night. Let me pull it up quickly. All right. Of the population health management payments, which will include the one care payments plus the diva payments that don't flow through one care, but will go in spirit of one care programs, plus what's included from a Blue Cross, again, estimates, about 10.5 million go to hospital-employed primary care, about 6.5 million goes to independent primary care, and about 6.6 goes to federally qualified health centers. And that is a direct product of the attribution mix. The payments for this particular initiative are all done on a per-member per-month basis. The per-member per-month amounts are identical across all different primary care types. We do not discriminate between any of them. So the way that those funds are apportioned is simply a product of the attribution landscape across the one care network. Theoretically, could you adjust that so that the payments are actually more favorable for independence or FQHC versus hospital-based? Theoretically, we could. That would be at the discretion of the one care board, and would have to be contemplated relative to the overall economics. But yes, in concept, yes. On the executive compensation, I thought someone said that the incentive comp, the bonus comp, has been achieved pretty consistently. Aside from the COVID years, can you give us a sense of how much of the bonus comp has been paid out? Sorry, that's a bad question. I apologize. What we just do last year, was 100% of the incentive comp paid out for last year for the executive level? I don't believe so, but we could check and tell you the proportion. I heard Dr. Merman say that he has not always received 100% of his bonus opportunity, and I assure you, Dave, that this year you will. All of the board members will. That would be helpful in looking at whether or not the executive comp and incentive comp is aligned with achieving the goals. I think getting a sense of the percentage of achievement of the incentive comp would be helpful to see. I'd like to put in a request that we see that for all years, what was possible versus what was paid out for the C-suite level. I do think that financial incentives make a difference. I would recommend, I think what Dr. Merman said, which is considering, if you're looking at the things that we're trying to improve, ED utilization, mental health, primary care, we have objective data here now available. It would be logical to me to tie executive comp at the organization to improving those numbers. If we're seeing the PCP levels go down, it would be great to see those objectives aligned. I think that would be helpful. I'd put in a plug that that'd be a good thing to do. On the mental health screening, the $1.6 million, I was wondering what happens if people don't do it at such a level that you have to pay out $1.6 million. Let's say there's only $500,000 of people that hit that metric. What happens to the other money? Great question there. As One Care has evolved and had a greater portion of its expense base in the population health management category linked to outcomes, it brings into play the reality that not every dollar will be paid out to the participants. We do not want to profit on our provider network. That's never been our goal is to earn a profit on the backs of the hospitals. I think there will be discussion and decisions around whether or not those funds would be deferred and essentially used in the next year as incentives or even refunded to the hospitals. That's a decision that our finance committee and the board will have to grapple with, but I can say with confidence that there's no intent for One Care to profit on funds that essentially weren't paid out through bonuses. Yeah, no, I get that. I'm just trying to understand where it does go. It would be the board votes on whether or not to pay it back to the hospitals. Or if there's a methodology to defer those funds to be used in the future year so that we can maybe limit or minimize some financial back and forth between One Care and its hospitals. And with the PHM bonus money, has there ever been years in which the full incentive amount was not realized? 22 will have some of that dynamic in play. We're rounding out our 2022 final care coordination reporting. So I don't have an exact number for you, but I do expect that there will be some funds left on the table, so to speak. So it's a newer paradigm that is starting to bubble up as we've, as I said before, advance the amount of money in you must earn at buckets. Okay. Yeah, so I'll put in a request for that too, for bonus money. I'd like to have some numbers on how much has been achieved in the past couple years and how much, which was not what happened to it and where it went because in evaluating the entirety of this program, when we look at the budgets, it's just on what is possible, but if a lot of this money is not being paid out and it's just going back to the hospitals, there may be need to have some tweaks. Sure. Because the incentives won't be as sufficient as hoped. And also how attainable are the goals to it, you know, balancing all that. Sure. So that there was a fairly drastic reduction in the number of FTEs, I think it was, I don't know where I put it now, but it was down to 47 from maybe 63 or something like that. And was that from the original budget submitted to the board to today, that reduction of all those positions? So there really is kind of a two step dance here. The first was a reduction that was between 2022's budget and the original 2023 budget that we submitted last fall with the biggest material change being the transition of the analytics staff. That was roughly 10 FTEs, nine or 10 FTEs. Then this go around, there were five FTEs taken out of the budget to accommodate the 2% admin cut. Looks like it's slide 18 where you describe those positions. How was it determined that those would be the positions that would be cut to implement the 2% admin cut? They were all vacant and we did not want to do any layoffs because we have plenty of work to do. We need every person that we have. So there was an evaluation. Oh, okay. Was the evaluation, have you ever had an evaluation manager? No, that was going to be a new position. Which has been cut due to the admin cut that the board implemented or required? Yes. And in turn, we in the revised budget took those salary dollars and needed to increase them fairly substantially to afford the evaluation contractor with the level of expertise that could do everything we described to you. You described for member homes some of the advertising budget, I think is $50,000 now. Is there any money spent on lobbying or is that part of the advertising or is that somewhere else? It is somewhere else. We do have a contract with a firm that helps us with legislative affairs. Where would I find that expense? Give me a moment. I can find the point. I don't want to delay the discussion here. I believe it's in a contracted expense line. I've seen that. And I just received confirmation from my amazing team that that is correct. In terms of the org chart, the staff did a presentation for the board on Wednesday with the FTEs and it looked like there was 5.75 FTEs for public affairs. Can you describe what that is and what the work is from the public affairs group? I'd be happy to take it. So I think that one of the learnings that I will take away from this process is that we could do a better job of describing some categories to you all of where functional work lands that some of our categories maybe just aren't as intuitive. So in public affairs as a bucket, it includes communications. So helping our team to design and review communications like the reports we've been talking about today to our provider network, getting the word out around the mental health initiative and helping us to identify the right audiences within our network to drive some of that change. It includes positions that are specifically supporting our board and governance committees through all of the work of planning and material execution and minutes and everything else that goes into that. It is also managing our website, thinking about our presence on those online forums such as LinkedIn or Twitter and a whole host of other internal communications and liaising with key stakeholders in our network. So making sure that we have regular engagements with representative bodies whether that be from the designated agencies or our home health agencies or others to make sure that we are hearing kind of what the needs and opportunities are from our network. The cut that occurred you may have said this and I apologize but the $300,000 or so that was from the board instituted cut where where did that money go? What was it used for or what is it being used for in this budget? It was essentially restored as population health management payments. It's a little bit of a through the chain but when we decided to ultimately leave the hospital participation fees flat any extra funds that we had available either through the 2% admin cut or other changes that occurred in the budget got reinvested into the network. I would echo what I think Dr. Merman said as well which was that the CPR program is generally we receive extremely positive feedback on that. Is there any plan to ramp up the financial investment in that? Yeah I think we are interested in both expanding the investment and the breadth of the program covering more providers and provider types. This was designed to be a program specifically for independent primary care when one care was really ramping up under the all-payer model era and since then we've grown to have a pretty good percentage of the independent primary care providers in our network participating but it starts to beg the question could something similar be overlaid from FQHCs or even hospital employed practices? There are some technical challenges to that but it's something that we're actively thinking about and working on. In terms of the level of investment we established in 2023 a linkage to the total cost of care which is a concept that has gained some traction both in Vermont and nationally. It's tricky to do it that way but it provides the framework for us to have kind of deliberate and transparent investment in primary care and trying to direct more of the healthcare funding pie into primary care practices. On the benchmarking there was a data point about the low spend on PMPM. It's slide 25 and I apologize if another member asked this and I'm repeating it but the ACO peer cohort is at the 50th percentile and all ACO national cohort is at 90th percentile. Is that a typo or is there a reason for doing it that way? It was available data so the way that the report comes out we only have the 50th percentile for the peer cohort and that's a product of the size of that cohort whereas the request from the staff to the Green Mountain Care Board in this latest revision was to include the 10th, 50th and 90th percentiles. So again just looking at what was available to us for data. Okay but you have the 50th percentile for the all ACO national cohort for the other measures just not for the PMPM costs. No it's available in the report for the PMPM costs. I could look it up for you. Sorry I might have misunderstood. So use the 50th percentile for these other measures that are in the presentation but the 90th for the PMPM. And I thought you said that was because that was what was available. No I'm sorry if that wasn't clear. So the peer cohort bar which is consistently the 50th percentile is the same throughout. The national cohort that represents 513 ACOs we did vary which percentile benchmark for different slides and if you want to go back to the prior slide that has the areas of strength and opportunity we've put in footnotes there where the comparison is to the 50th or the 90th. So trying to be as clear as we are we are not trying to ever claim we are better or worse than we are but in terms of trying to think about where there is opportunity for improvement and who we might reach out to and how we might connect we're trying to be a bit more focused. And I don't think I guess I'll ask. You don't have information available for the PMPM costs for Medicaid or commercial right. We don't. We have explored that together with your staff and there is some very nascent work happening but no one that has to our knowledge pooled the data in a cost effective manner and has been able to kind of get through the processes particularly in the Medicaid population around the differences in plans from state to state. You know I think we're hopeful that we could get there over time but it's really going to be watching what happens nationally as well in terms of aggregators of that data. But you have your settlement amounts over the years for just yeah okay. Correct. And based on those has one care been below total cost of care for Medicaid and commercial such as it has for Medicare or would there be difference in results? Starting with Medicaid I can speak to this. We have a very strong track record and I recommend looking at the Medicaid results year-over-year in a way that combines fixed payment performance. In other words performance under that fixed payment and the shared savings result at the end of the year. And I think all but one year one care has beat that total cost of care target. So it's been a strong track record in that program. The commercial landscape has been a little bit different. I think it's been harder for us to perform and some of it might be dynamics due to the way the target is set or methodology but we do not have a strong track record in the commercial space. And I would just add don't forget that in the quality space there are national benchmarks for Medicaid and for commercial insurers and that we present that data every fall to you all. Right. On the commercial so obviously you know our commercial expense in Vermont is exceedingly high. We're very low Medicare cost is exceedingly high commercial. So I mean looking at from the pressing problems facing Vermont to the extent the ACO is having an ability to perform well on Medicare it would be really great to see it perform well on commercial where they've really been suffering from large increases. And I think Mr. Boris you alluded to part of the challenge being in how the targets were set. Is that to suggest that the targets are more ambitious for commercial. I think in the commercial commercial market it's challenging because of the magnitude of change that occurs from year to year and the public payer programs pretty stable increases from one fiscal year performance here the next that makes it a little bit more reliable to set a fair benchmark for the providers to go and be in the commercial marketplace especially lately where there's been some very significant inflationary or cost increases it makes setting that target more challenging. And I think we've faced those challenges through the years of how to make sure we have a good fair target that gives a good fair result at the end of the year. I don't want to hold up wounds here but was that part of Blue Cross's decision to pull out was that they weren't seeing the savings. I know there's the data issue I think they put in the press release. I don't believe they specifically reference the target methodology but we'll say that one care worked throughout 2022 collaboratively with the actuarial team from Blue Cross to come up with a revised target methodology that we felt like would be an improvement for 2023's business and it changed the way that the cost evaluation was going to occur was planned to change that. I don't know this would be a question for them but it was never communicated to me that that was a concern that would have caused them to not contract with us in 2023. And I've been taking away from your comments that in one care's view there's not really any I don't really love the phrase but fat to trim off the budget that everyone's working very hard and there's no real places for additional savings. I sent a letter to one care on February 9th encouraging one care to consider whether there are further reductions in the admin budget that could be better utilized to support primary care. Could the one care budget be smaller and could that money be reinvested in primary care some of the major challenges we're seeing in the benchmarking data. And so my question is whether or not those that was considered and what you looked at and what the outcome was. Certainly considered. One care has over a number of years really worked hard to thin out its infrastructure as much as possible in spirit of reducing the dues essentially charge the hospitals by appreciate your point about how to reinvest those funds in primary care as well. Going back to what Sarah said eloquently before there are just core functions that need to be fulfilled for us to operate these programs responsibly. It's a huge responsibility my opinion to manage these programs are a tremendous amount of dollars linked to them and the financial stability of providers particularly those accepting a fixed payment. So we face a tension between how deep we can cut and can we continue to responsibly can facilitate these programs in the future through time in the future may operate make available to us some different changes or structural changes we can make. But right now we our cup is overflowing and we felt like it was very important to sustain the level of infrastructure we have now to both support what we have going on but what might be coming down the pike and a future iteration of the all pair model. You've described a number of changes that have occurred from the budget that the care board originally reviewed in fiscal year 23 and what what you're presenting today. I assume that you've been operating consistent to date with what you've been presenting today. That is correct. And we're I'm talking about the BCPS withdrawal the UVM self-funded the MVP lives change and risk population health management payments all of those would you agree with the characterization those are significant changes to the budget. We feel that we've communicated all of those transparently to the Green Mountain care board both through the hearing process and through all the subsequent documentation that we've provided when requested or proactively. So so those seem to be fairly significant changes right the amounts of money being paid out the number of lives the payers the whole it's a big change and I guess my question is has one care requested a budget amendment. We've not requested an amendment and our council did not believe it was necessary. And have you communicated to the care board why a budget amendment would not be necessary if your performance to date is not consistent with the budget order that's in place. Our council has spoken with your council I was not there so I can't characterize the conversation. On the benchmarking I understand that you know there's you described eloquently how they were done the different benchmarks that were used on the vendor recommended version. It's obviously important for us to have comfort that the methodology used and the comparison ACOs are appropriate because if they're not then the data is really largely useless. It's it's like comparing myself to an Olympic skier versus somebody who's never skied it matters who you put me up against. Although the people who've never skied up and will probably scale up better than me too. I know our staff has asked for some insights into that and I would just emphasize that that's extremely important because otherwise this data is largely meaningless. I can't have comfort that it's right until our staff has a chance to appreciate what was done to get the methodology. My understanding is those requests have been going on for a while and it's a little disappointing that it's coming after two hearings on this but I would like to make sure that that happens promptly so that we can be sure that what we're looking at makes good sense and I'm sure it does but we definitely want that comfort. My understanding is that meeting is scheduled for next week. Great perfect thank you. I don't think I have any other questions at this time. I don't so thank you all very much for your answers and for your presentation it's helpful. Oh yeah sorry and actually too I think Dr. Merman and maybe Dr. Jess Holmes have a question as well. Go ahead Dave. I just have a few follow-ups from things Chair Foster brought up. So with regards Tom you mentioned about the approximately was it 10 point something million dollars that goes to the hospitals that's for fixed perspective payments for hospital-based primary care providers correct? No that's separate from the fixed perspective payments. These are payments linked back to the population health management program itself which is separate. Okay right right so it'd be far more I'm just trying to figure out are there what is the total amount of money that would be paid out to member hospital-based organizations that would be beyond what they would typically receive for those services. So you're bringing up a great question that is one of the challenges we're facing in the CPR program expansion work is how to take a hospital organization and cleanly delineate what's their primary care work versus other hospital work. Based on the way the billing occurs that line is more difficult to figure out than one might think. So we when we evaluate at least that present the performance of a hospital it's more in aggregate to the hospital in total perform well relative to their fixed payment or do they have overruns and we've seen both occur through time. But part of the goal of the CPR expansion is to figure out a way that we can reliably measure the primary care component of a hospital organization and then establish over that the CPR methodology or framework. Okay I guess my question gets to the idea that if if hospital dues are 15 roughly 15 million dollars 14.8 million dollars and 10 million is coming in population health management payments you know so so does that mean they're that's money that's going back to them the effective buy-in they have is five million dollars to for one care is that a fair description. In aggregate I think you're capturing it properly. I'm happy to help validate the numbers but in aggregate yes there's an investment that the hospitals make in the one care infrastructure and then they also help to supplement the PHM program on top. So some of the money that they get back actually might be coming from them in the first place. So we it's a complicated funds flow but a hospital in my view should be looking at their hospital participation fee expense but also relative to funds flow coming back to them through value-based care programs. So it's kind of a way for us to affect where the funds go what are the accountabilities under those funds and champion the concepts of value based care. And in the all-payer model arrangement through the way Medicare benchmarks are set do the does that give the hospitals overall a higher payment than they would get if we were not in an all-payer model agreement. A great question it gives them a potential for higher payment not a guaranteed. So essentially the way the Medicare program works is that there is a target delivered that has that inflationary trend that this board approves every year believe it was 5.2 percent for 2023. If a hospital is able or the network at large is able to live within that 5.2 percent trend financial benefit materializes through shared savings. So it's it's a not a guarantee of additional revenue but it's an opportunity to earn additional revenue through effective population health management. And how would how would the last fiscal year look with regards to that? Last fiscal year is projecting to be favorable again at present based on the data we have. We believe we'll have enough shared savings to cover the blueprint expense which is very important priority and then a little bit of extra shared savings for the providers which is both primary care providers and overflow to the hospitals. Because of the narrower risk corridor which is a product through the pandemic and as well as the financial health hospitals there's not that much financial potential for hospitals right now. So it's you know maybe a million that would get allocated across all the network providers through our risk sharing model. So would you say from your perspective looking at this that overall it's financially neutral or advantageous for hospitals to pay dues into one care to support one care's activities as opposed to a cost to them. We've had good results in the past net favorable results through time which is great. That means that one care can continue to support its providers and creates to me what I hope is the virtuous cycle. So I think that's great. I also caution any participant in our network to think about or not to think about shared savings as a reliable revenue stream. I hope we beat it every single year but the reality is that it's a new paradigm. Some years will be shared savings. Some years they're shared losses but shared losses to me it's not the preferred outcome obviously but it is the system at work. It's the provider saying we didn't deliver care as efficiently as we promised. Therefore there's a payment back to the payer. So I don't think that's a bad thing inherently when it does occur. It's really why these cons programs and concepts make sense to me. But of course I hope that we can deliver shared savings every year the providers and then use those financial gains to reinvest in the future of what one care is trying to do. Thanks. I just a few more chair Foster mentioned this observation that one care is very focused on primary care and care coordination which makes me you know the idea of keeping people out of the hospital to reduce overall total cost of care and cost. That said you know we can look at the numbers exactly but I think it's similar but 9.7 percent of funds go into primary care. So the bulk the vast majority of funds are hospital based activities. Does one care have any programs or ability to develop programs to try to reduce hospital associated costs. I think all of our programs in some way or another are designed to do that and this is where you know I'm a champion for payment reform. As opposed to prevention of receiving care in the hospital the actual care delivered in the hospital. Is there are any programs that can that that one care has or could potentially develop or is it sort of out of the scope of one care to try to manage hospital costs. I would say it's Sarah. Well I would just say this points back to some of the critical questions you all have been bringing up today about you know kind of what's the size of one care and the investment and where are the opportunities to improve. So we've had conversations over the years quite a few of them about should we could we how would we develop programs targeting specialists or targeting specific inpatient experiences and to date we've had to make the tough decision to focus our energy in the community. So in primary care with our continuum of care partners that's not to say there aren't great ideas out there or things that could be done but with resource constraints we've had to make that tough decision not to go there thus far. Two more things you mentioned Sarah since we were just chatting about the peer cohort not being able to get because the cohort's too small you can't reliably calculate a 90th percentile. For comparison is that the am I saying that. You can technically calculate it and it was calculated back in the fall the N is two ACOs when you do that. But my understanding of the way that that was calculated is that you pick the two highest performing ACOs and then from a cost the two lowest cost ACOs and then looked at them so they're not and I think the staff was interested in seeing and the discussion was that in each one of those metrics who's the 90th percentile performer in each metric could that be calculated. Yes to my knowledge that could be calculated. Because I think that was sort of an interest of the staff and the board was to understand that high performers giving the complexity that a high performer in one area may be a low performer in the other area and that that we understand that those things are maybe counter related and opposite for some reason but trying to understand where a high performer whether it's a 75th or a 90th percentile in each one of those light items would be I think that's how you approach the all ACO comparison group correct. That is correct and I should just note we can continue to iterate forever on drafts and we are happy to continue conversations about improvements that are crucial. Every improvement requires more money be spent because of the way this contract is structured to try to meet the baseline budget order requirements. So there's an expense associated with the vendor obtaining the data organizing it generating a report and then we pay hourly for everything they do. So we we can do that and we are happy to have that conversation but ultimately we are hoping to soon get to a final template that we could provide consistently on a semi-annual basis and therefore minimize some of those development costs. I totally agree. I was just trying to understand how you were referring to that that data. So I was just trying to understand if that each one of those lines was had significant skew to it or if it was if it was really difficult to interpret those centiles but but it's ultimately for me I think in our team it's the directionality that we're interested in and you know the signals of where we might be far off where we're a deviant from you know whatever benchmark you want to identify. Ultimately this is a tool to improve care for us and so that's what we're really trying to pivot to. We've spent the last year or more trying to develop the methodology the actual reports. Now we want to use the information. So yeah I think you're asking good questions. You know I think it's certainly conversation we could have with your staff as well next week when we meet with a vendor and then my question is just kind of what's good enough and through which lens for us to be able to move forward. And I agree that the change over time I mean a lot of these things that we talked about over and over again you know our low total cost of care for Medicare patients Vermont is that one care is responsibility in doing or is that where we are and what we're interested in is sort of what's the effect that can be changed over time in these various these various data points. So I appreciate that understanding. The one last question I have for you goes back to the executive compensation. Actually it doesn't go back to the executive compensation. Well it's related to but it's the 2 percent budget order and I guess the question that I have is was there ever a consideration of reducing you know given the salary structures through youth and health network of executive salaries based on the 50th percentile with bonuses up to the 65th where most other salaries are more I believe in the 40th the 50th percentile was there ever a consideration of reducing executive salaries as opposed to not filling open positions and thus offloading some of the hard work that the workers at one care are doing. We had already taken a step in that direction probably didn't discuss it with you publicly back in the summer or fall but when it came to inflation and compensation adjustments we already had made a move to be able to differentially provide increases to staff under a certain threshold of annual income and so that was already considered. I think to your point we really pay attention to the way that compensation relates to national market scans and likenesses between appropriate positions. So we did not make a decision or a board did not make a decision to cut those specific salaries further through the 2 percent admin instead we looked at the vacancies and other savings that Tom Boris described already. And is still the salaries for non executives at one care are they based in the 40th to 50th percentile compared to national benchmarks where executives are the 50th with bonus up to 65th? I would want to double check that for you Dr. Merman I believe I saw some data that suggests that it's higher than that 40th to 50th but we we can get that. That would be really helpful thank you. That's all I have thanks. I have two quick things one I made a quip about Dr. Merman's bonus I should just clarify that that was a joke and there are no bonuses for care board members but I have a lot of admiration for Dave's work and the quip was supposed to reflect my admiration for his contributions to the board not that we actually get bonuses because we do not. Second on the hospital PCP payments you know ten million dollars I think it was is a lot of money and I received a message that generally the answer when we asked hospitals this was that the money was not being dedicated to primary care that it was going more towards general operations so if that's accurate then that's a very large amount of money that is in the one-care budget to support primary care that may not be pulling through all the way so I think that's something that is an opportunity to think about how to ensure that that money is actually achieving what it's there for because these numbers sliding backwards and the benchmarking report for primary care is really really concerning and if ten million dollars of the primary care provider support money is not pulling through that's a big big big difference in the budget so I just wanted to flag that and I haven't diligence that myself so we should look into it but I think I just want to flag it and with that I'll turn it to the health care advocate for any questions or comments thank you so much Ms. Holland can you hear me okay yes you sound good thank you great thank you so much for all your work today for the record San Paes health policy analyst with the office of health care advocate a couple questions and then a couple comments the first one kind of more specific question if that's all right it's a great point from the adaptive report that one care submitted specifically in the staffing FTEs in the previous budget submission for FY 22 there was kind of breakout categories for value-based care there was like analytics quality care coordination and prevention and now it seems like they're all uncategorized so I just wonder if you could elaborate on that sure from an operational perspective it's because as part of this effort to simplify and focus we unified the team under the umbrella of value-based care and this evolved Sam as we then were also making the transition of our staff our data and analytics staff into the new arrangement so our care coordination our quality staff they're all working in a unified fashion to support these strategies okay thank you that's what I figured but just wanted to clarify I want to thank member Holmes and member Lund for the questions around the mental health screening project and just follow up a little bit on that I think as we all know we have a deep provider shortage in the state particularly mental health providers and therapists so I'm wondering if you have given any thought about the ramifications of you know supporting increased screening which will very likely result in an increase in mental health diagnoses or diagnoses independent of incentivizing at least it doesn't seem like there's any corresponding incentive for increasing access to providers so I'm just wondering about the scenario where more people are receiving diagnoses but you know many people are experiencing challenges finding someone to take care of their needs I can answer from my perspective the initiative will supply money to primary care if they perform the duties you know the if they agree with the what we have set forth in that policy I don't see that it's going to cost them a lot of money to make those improvements and therefore they could use that money to supply more mental health provision so that could be telehealth that could be a part-time behavioral therapist in their office it's up to them what they do with that money but there shouldn't be a great expense to do more screening screenings already something we do a lot of people are just not recording it in a field where it can be digitally reported so I think you know if it were my decision in my practice I would probably use some of that money to expand mental health provision whether it's my own time or a specialist of some sort a mental health trained person or telehealth for that matter that's helpful thank you in response to some of the board questions this relates to the relationship or maybe not relation lack of a relationship with uvm's population health services organization you wrote in part I'm quoting the population health services organization is uvm health network solution to improve population health management and performance and value-based contracts across its affiliates its focus is on providing high quality actionable data to modern improved performance in this way its goals are similar to one care is just the different reach I'm wondering if there have been any discussions to date about one care's relationship with the population health services organization and if it's going projected to change in any way Sam thanks for your question I think you know we're continuing to explore the functions that the PHSO is building out and the results that they will get you know be they fantastic or otherwise and I think there's opportunities in that space for facilitating that dissemination of best practices I think you know it is our job at one care is management to look for any duplications any efficiencies that we can gain and that's a continual process for us so that would include you know are there things that the PHSO is doing that maybe one care wouldn't need to or vice versa so that will be something that we do on a regular basis there's nothing definitive you know at this point okay thank you that's helpful just a couple quick comments to close that and I'll turn back to you chair foster I want to support chair foster's concerns around the benchmarking report analysis as well as the need to kind of cross account and crosswalk those payments to primary care whether or not it's being utilized I think it's important to really get more clarity about that and just briefly around executive compensation we are concerned with how this executive pay structure and the process measures that connect to it look to Vermonters and what it says to Vermonters who are struggling to afford the care that they need we don't dispute the UVM health network has the right to structure its corporate compensation as it sees fit with its local board and board statues and rules but by law because one care is a part of the network it is still an accountable for care organizations subject to rules and requirements of ACOs in the state so those are different from the ones that govern hospitals so I just want to make sure that's that's clear thanks thank you and with that I'll open it up to public comment via the razor hand function miss Wasserman how are you please go ahead thank you I'm fine I have a couple of comments and a couple of questions the first issue is the administrative costs of the ACO which have been discussed quite a lot today at Wednesday's meeting with staff presentation it was described as a 2.6 percent reduction from the original budget to the revised 2 percent of that 2.6 percent was mandated by the green man care board due to the affordability crisis and so I'm left wondering if the 0.6 percent is all that the ACO has reduced its administrative operations budget even given that they've lost 22 to 30 percent of their attributed lives now I understand and it's been highlighted today that there are fixed costs but we were talking about real money here $15 million a year and over the course of the seven years we're talking $100 million as I want to underscore $100 million is a lot of money and I guess the question is even though these are fixed costs what's the return on investment and I'm asking that rhetorically so I don't expect you to answer it but I think we all have to look at the question of what is the return on investment my next point is that this issue of the population health payments to primary care physicians and the issue of so much of it going to the hospitals 10 and a half million and a chair fostered just describing that much of that goes to the hospital's bottom line a couple points I don't think that the that one care can continue boasting about all this money that they're giving to primary care to make primary care stronger and more fortified if they they can't even actually account for the 10 and a half million that goes to hospitals and in fact if that 10 and a half million dollars doesn't go towards primary care improving or fortifying or strengthening primary care I don't think you can continue to represent it that way I'd also like to point out that the data that was distributed that was presented today the independence are bearing more risk than the hospital-based primary care physicians so I think that's a pretty important thing they're bearing independence are hanging on by a shoestring they're hardly surviving in a situation where we have a crisis in primary care and access and yet they're bearing more risk I don't know which slide it is but they're bearing more risk than the hospital-based primary care physicians that was a slide earlier in your presentation today in terms of primary care the and the access problem that's been discussed today yes it's true the problem is very systemic but my question for one care is why hasn't one care made good on its promise to increase the number of primary care physicians or expand capacity and as I've said in some of my written comments this was one of the biggest issues in 2016 when the ACO and the all-pair model was coming into fruition they were promised they promised to address our primary care access problem and Dr. Merman you you asked whether the one care has initiatives to reduce hospital costs and in the same vein as the only ACO in the state with hospital costs escalating my opinion is that one care should definitely address that issue and my final comment is with regard to the mental health the new mental health 1.6 million to primary care to do mental health screening and follow-up it's been implied but I'll say it openly I think it's a bit of a hollow proposal that pretends to address the mental health crisis but it doesn't really do so and that's because as people have said primary care physicians can identify many patients who need mental health services but there's nowhere to send them and yeah sure the extra money can be used to maybe bring in some mental health resources as Dr. Wolfman has said but many of the independent practices are struggling to survive and I I'm not sure that that it would work that way but most importantly Dr. Wolfman you did mention that that referrals could be made to the DA's but I'd like to point out that this new one care revised budget cuts the DA budget by 44% and so it's a that's why I suggested that this is a bit of a hollow proposal because we're asking for more for more we're asking practitioners to make more referrals for people who need services but one care is actually cutting the DA's who provide mental health practitioners and as we all know there's a huge shortage of practitioners and we can't pretend otherwise thank you Mr. Davis your hand is up please go ahead thank you Mr. Chairman I just have two comments first I think is that there's a sort of an error of unreality here the green I think that the one care Vermont complicated multifaceted but it basically doesn't have any power any power to affect hospitals at all the hospitals are going to do what they want to do if they if the one care can help them they'll take that if but if they see something they're doing something that is not necessarily a good thing to do they're going to do it because they think they need the money and there's just nothing anybody can do about that the only one that can actually do anything about it in fact is the green mountain care board they're the only ones with power okay to move hospital budgets the second thing I'd point out is the major effect of one care Vermont it seems to me is it flows from its essential its its origin in in Obamacare and the tie of that that issue to shifting from beef of service reimbursement to to um capitated care if you the network the uvm network has has about 60 of the care but the other 40 percent of the care is all fee for service straight out fee for service if somebody you or anybody else either either they say the green mountain care board or the federal government wants to shift the 40 the spending in the 40 percent of the non uvm network money if they want to shift that from fee for service to capitation it's only what what the cotton what the federal legislation contemplates is that that's what you would use a that's what you would use an aco for that's mainly what it's its purpose is now the question there's nothing the one that one care itself can do to advance that really they can talk about it and they can have been covered and all that so and so and so and so but the reality is that the that in in order to go to get in order to get that 40 percent of your totals hospital spending in from fee for service to capitation is is is going to be is is is simply going to be you're going to is you're going to have to get those 40 percent of people into a into a aco that's what an aco is for and so that is that is the fact so the so the evens at the role of this time the value of the of one care vermont is still essentially potential thank you i recently got some feedback that one thing i should be doing with public comment is that folks were associated with a regulated entity or previously associated or received compensation from regulated entities that it be disclosed because a lot of people don't know you know someone worked for vaz what that is or whatever else so miss waserman do you work for a regulated entity or have you received compensation from one and mr davis same question uh thanks for the for the question i do not work for a regulated entity and i do not receive any compensation my work is pro bono thank you mr davis i my turn i worked for i worked for fanny allen health care in the early 1990s about 25 years ago and i have no have not those last 25 years i've had no connection whatsoever with any paying industry my wife would tell you that great thank you um and i see one more hand up i believe it's mr hopin mr hopin up i'm aware that you previously worked for one care i think a while ago but i'll let you go ahead please thank you chair foster uh it was a brief tenure um i will uh i'd like to pick up the subject of crisis um when we look at organizational crisis and in many respects i've voiced this before you all function as the the board for the board of trustees for this organization in many respects and when trustees look at an organization they steward that's in crisis we have the option to either uh defer and allow uh as hemmingway said bankruptcy to happen slowly and then all at once we have the option to um refine the mission and to take away from the crisis the signals that tell us what are our core functions and where have we failed um for once i agree with ham davis and i underscore member walsh's assertions this is largely a uh payment disbursement mechanism at this point um we cannot even account for necessarily how payments are disbursed to the primary care providers that they're meant to arrive at rather than falling to the bottom line of a hospital so when we talk about fixed costs in a crisis uh everything becomes variable as member walsh said and we begin to look at how do we refine this down to what is essential so that we can uh not risk a total loss and let's be clear a total loss to the state would be our um discussing what became of the hundreds of millions that we attempted in this over the last couple well rather seven years um a couple more comments on crisis uh you know the the impetus or the the real signal that there was crisis was when essentially the only commercial payer in the state pulled out and spent roughly five minutes during the fall season telling us that they they just can't point to any benefit that they've gained from their investments over the years um so it's it doesn't go unnoticed that there was no mention today trying to signal some encouragement about the state of the crisis by suggesting we are back at the table in 2024 looks optimistic um and I will say that more concerning if there's ever a signal in the corporate world of the severity of crisis it's that leadership jumpship and take off and so I'll just point out the elmfin in the room today the ceo of this organization is determined that um they are better off elsewhere after telling us for years their um lifelong devotion to Vermont healthcare reform and it being the raison d'etre for their uh work in the state um lastly I'll just point this out it's probably unknown to many of you that today rather than taking up uh legislative bill s9 in uh house government uh and military operations they've chosen to take up uh 39 which makes sure that before they leave the session they'll all have access to the most affordable healthcare which is free healthcare um they have decided to forgo bringing up s9 uh which was precipitated by an independent agency elected body in the state and the um state auditor's office diligently trying to make sure that healthcare was as affordable as possible for this state and so um through a really misfortunate um judicial ruling powers were clawed back from the state auditor's office precluding its ability to um represent Ramonner's interest in having the most affordable healthcare they can um I guess I would ask this board today since since what the legislator legislature has been telling mostly representing the many lobbied interests that have showed up uh telling the auditor that the auditor can get the uh information he seeks from the state agencies rather than the contractors what prevents this board from conditioning an approval of a apparently non-amended budget request that should have been amended um would they finally agree to give you the documents so that you could then convey them to the state auditor so that vermoner's in the midst of an affordability crisis could have confidence that what scarce dollars there are in the system have been spent as they were intended thank you thank you for your comment um and I did see miss loner that you have a new position I want to congratulate you and thank you for your work here in the state and um we of course look forward to working with your interim and future uh management so congratulations and thank you thank you very much and I just wanted to say that um my decision to leave one care was personal given the point of time I am in my life right now and other commitments I have and have nothing to do with my devotion to healthcare reform and for vermoner's to live a healthier more fulfilling life in Vermont so just to correct any assumptions made by mr hoffman about my intent great thank you um I don't see any other public comment at this time is there any new business to come before the board any old business and is there a motion to adjourn so moved second second oh we got all kinds of action I like it all right all those in favor please say hi hi hi hi all right thank you very thank you very much one care your team you put in a lot of work and appreciate it have a good day uh could I just ask a couple of quick questions mr foster if it's no trouble um please do you just need me or do you need everybody uh well actually I need um let's see I had a question for mr boris and mr mermin mr boris you mentioned when you were talking about yes but that's all that's the only two I had questions you mentioned when you were talking about um the budget um did you say a lot of advertising went to mont digger I'm so sorry I'm sorry vermont digger oh of course oh sorry sorry yeah well I've got a bit of an accent vermont digger thank you so much and then we talked about um um uh mr mermin you talked about uh the er did you say in chip men county oh chitenden could you spell that for me ch i t t en d en thanks so much and then just a couple more mr hoffman's does anyone know mr hoffman's first name by any chance robert and rt thank you so much and then um oh I just wanted to ask who seconded at the beginning of the meeting I heard mr walsh I believe and did mr mermin second the minutes at the beginning of the meeting as well I believe I did you did okay uh thank you mr uh foster for allowing me that time to get that uh clarification and I'm all set thank you all so much of course have a great thank you thanks thanks