 Good afternoon and welcome to the Green Mountain Care Board. My name is Kevin Mullen, Chair of the Board, and I'll call this meeting to order. I see that all four board members are present. So at this time I'll call on Susan Barrett for the Executive Director's Report. Thank you, Mr. Chair. I do have a few announcements for folks today. First, I wanted to start with several ongoing, open, special public comment periods we have. The first one, which you're going to hear a lot more about today, is on the 2022 FY22 Bank Care Vermount. Oops, there's a little bit of an echo. So if you're not talking, you could put yourself on mute. Thank you. The FY22 budget and certification. So we're asking that folks share public comments by December 17th to be considered before the potential vote from the board, which is tentatively scheduled for December 22nd. It is scheduled for December 22nd. In addition, the board is accepting public comments through December 13th on the proposed red line and request letter for the all-payer model agreement, the proposal to request a one-year extension of the current agreement. We would ask that you submit those comments, as I said before, at the end of the day, but on December 13th, so that the board can consider those comments before the potential vote scheduled on December 15th. And separately, not to be confused with the one-year extension proposal of the current agreement is an ongoing special public comment period that we opened up back in February of this year. And this is for any comments regarding a potential next agreement between the state of Vermont and CMMI. And any of the comments we receive, we share with our colleagues at AHS and at the governor's office as they are leading the negotiations on a potential next agreement. I'd also want folks to just be aware that over the next few weeks, we have pretty busy schedules and important decisions that we'll be making. So I just want to take these off quickly. This is on our website under our public meeting portal and first, next Wednesday, we'll hear from our staff on the 2022 Medicare benchmark proposal for the all-payer model. We also have a potential vote scheduled for the 2021 update to the health information exchange strategic plan and 2022 connectivity criteria. And then we also have a potential vote scheduled for the all-payer model agreement proposal to request a one-year extension of the current agreement. And then next Wednesday night, we have our primary care advisory group meeting from five to seven. And at that meeting, we're going to hear from Vermont Medical Society on their primary care platform for prioritization. The next week, which is the 22nd of December, we have a potential vote scheduled for the FY22 one-care Vermont budget. We have a potential vote scheduled for the 2022 Medicare benchmark proposal for the all-payer model. And then we've also put another placeholder of a potential vote for the all-payer model agreement proposal to request a one-year extension of the current agreement. So lots upcoming and going on, but I will turn it back to you, Mr. Chair, so that we can hear from our staff on their recommendations on the one-care Vermont budget. Thank you, Susan. The next item on the agenda are the minutes of Wednesday, December 1st, is there a motion? So moved. Second. It's been moved and seconded to approve the minutes of Wednesday, December 1st, without any additions, deletions or corrections. Is there any discussion? Hearing none, all those in favor signify by saying aye. Aye. Any opposed, signify by saying nay. Let the record show that the minutes passed unanimously. At this point, I'm gonna turn the meeting over to Sarah Kensler and Sarah, if you could introduce the team and we will proceed with the preliminary staff recommendations for the 2022 one-care Vermont budget and certification. So Sarah Kensler. Thank you very much, Mr. Chair. Can you all hear me okay? We can. Great. For the record, this is Sarah Kensler, GMCB's Director of Health Systems Policy. Here with me presenting today are Marissa Melamed, Michelle DeGree, Patrick Rooney, Russ McCracken, Michelle Sawyer and Julia Bowles. And I believe Michelle Sawyer is going to put our slides up to project while I get us started and kind of direct for the whole show. Thank you, Michelle. All right, so on slide two, we've included an acronym list up front just as a guide since we know that this can get pretty jargony pretty fast, but we've also tried to make sure that we introduce these terms when we first use them as well. On the third slide, I'm just going to walk us through a quick agenda. First, we'll provide a bit of introduction and background as well as reviewing the public comment that we've received to date. Then we will walk through the FY22 staff analysis and preliminary recommendations and the text box here on the bottom right shows you what those key areas of review are that we'll be diving more deeply into. And then we'll talk about next steps, have, you know, board questions and discussion as in then public comment. I'm going to hand it over to Marissa Melamed now on slide four. Marissa, I think you are muted. I apologize. Thank you. Good afternoon, everyone. This slide you're seeing now should be familiar to all of you, just a reminder that oversight of accountable care organizations is falls under statute in 18 BSA section 9382 and Green Mountain Care Board rule 5.0. We are going to discuss both certification and budget review today. Certification occurs one time following application for certification by an ACO and eligibility verification is performed annually. But there is no, if there are no changes to the or enforcement of certification, then there's no board action that is required. Budget review works a little bit differently. It does have to be voted on and approved annually. And then a reminder that we are still in the season of contract negotiation. So budget review occurs concurrently with the contract negotiation and these contracts were not currently finalized. So the numbers are prepared based on one care's best estimate as they currently see them. And once contracts are finalized, we have them come back in the spring with updated numbers to present a finalized budget. So it is really a two-part process. I also want to make a note that for this review, the Green Mountain Care Board has brought together an interdisciplinary staff team. It consists of our policy team, which looks at payments and care models and intersection with the all payer model. Our finance team, which does the financial analysis and intersection with hospital regulation. Our data team reviews results, evaluation and looks at all data systems and data issues. And then we have our legal team, which looks at compliance with statute and rule. You can move on to slide five, which is just a reminder of the timeline. So the green line there is today, it's our staff presentation. There's a number of steps still to go in the process. Today, it's just your first look at our preliminary recommendations. Excuse me, a vote needs to happen by the end of the year, but it is tentatively planned for December 22nd. If there are any issues after today that need to come back before the board, we can do that at regularly scheduled board meetings or scheduled meetings as needed to make sure that we can resolve issues in time for a vote. The Medicare benchmark and the Medicaid advisory rate case are separate from today's conversation, though they do happen concurrently in December. So it's a very busy month. And that Susan mentioned is on the schedule for the 22nd, I believe. So the vote happens by the end of the year. The Green Mount Care Board issues a budget order, usually in late January, maybe first thing in February. The final contracts and final budget is reviewed in the spring. We also develop guidance and any benchmarks for the 23 budget in the spring, and we monitor one care's actuals and performance against the budget and conditions ongoing. I think it's been said many times now, but public comment is accepted throughout the process and should be submitted by December 17th so that we have time to review it in time for subsequent discussions or deliberation. And now I'm gonna pass it to my colleague, Julia, for an overview of public comment to date. Perfect, thank you, Marissa. And can I just get a nod that folks can hear me? We can. Okay, thank you so much. Yeah, so as Marissa said, the next two slides give a summary of the major themes of the public comments we've received this year. In total, as of yesterday, December 7th, we had received 43 comments. And I wanna note that the themes on the slide here, as well as questions and comments that were raised sort of outside of what's reflected on this slide are addressed in detail throughout the presentation. So I'm just sort of giving that summary, but for folks who commented, I expect to see those themes reflected later. So four of the central themes that we wanted to highlight from the public comments were first, the value of OneCare's data and analytics to providers, especially for population level insights and prevention initiatives. Second, the value of care coordination investments that are enabled by OneCare funding. Third, concerns related to the decrease in population health management and mission-related investments. And fourth, concerns related to OneCare's leadership compensation. So the next slide summarizes specifically public comment from the healthcare advocate. And okay, I'm sorry, just took a second to change on my end. And so as a reminder, the healthcare advocate under the ACO oversight statute has the right to ask questions, receive confidential materials and provide testimony in any ACO budget hearings, which is why we wanted to specifically highlight their comments through its own slide. And we also want to extend a special thank you to the HCA for their thoughtful engagement throughout this entire process. So as you can see on the slide, the HCA provided comments on four major categories, which were population health, transparency, evaluation, and cost estimation for remonters, all of which are covered in future slides. So as Marissa already said, but as I will remind folks, and as Susan already said, we are still open to receiving public comment. We just ask that you get it to us by December 17th, so it can be considered ahead of the board's vote. And with that, I will pass it back to Marissa. Thank you, Julia. I think Julia and I are gonna go back and forth a little bit because she's going to help me with this high level staff analysis, but I just wanted to say a quick word here. You can go, actually Michelle, to the next slide. This is what we're gonna do now is a high level overview of the budget submission and our approach to the review and the staff recommendations this year. These are the major sections that we're gonna talk about in the high level overview, the provider network, the payer programs, the income statement. These three things are summary information that's pulled directly from the budget submission, things that we thought would help sort of ground the conversation. We're also gonna say a word about the impact of COVID-19 and then our approach to the recommendations this year. A note that I wanted to make here before we proceed is that we review a high volume of material. Obviously, you can see this is a large slide deck and it's because it's our sort of step-by-step review of all the different sections. But the amount of material we review consists of, I think it's 129 pages of budget narrative, two rounds of questions of which are dozens of pages as well as reporting that comes in continuously throughout the year. So it's a high volume of material, which is why there's so much information and we do our best to boil it down to the categories that are most important to understanding the budget and also significant changes that we've noted from year to year. So we hope that we have been able to take this large volume of material and present it to you in a clear way to help with your decision-making. And I believe, yeah, the next slide goes to Julia to give us some of that high-level information. Slide. Thank you. Yeah, so starting with the high-level overview, we wanted to give just a very, very high-level picture of the provider network this year. And all this information, as Marissa said, is pulled from the submission in this one. In particular, this information is easily found in the budget narrative. And overall, the changes in the provider network are minimal this year and were typically due to mergers, acquisitions, and retirements. And in summary, as you can see on the slide, there were no changes in the number of hospitals or federally qualified health centers participating in the network from fiscal year 21 to 22. And of note in this third bullet is the addition of two independent primary care practices who have opted back into the comprehensive payment reform program for 2022. And more information on the provider network is found at the end of this deck in the reference slides as well as, again, in the budget narrative. And finally, on this slide, I want to highlight that approximately 90% of Vermont primary care providers participate in one care's network. And this is according to estimates derived from the Vermont Department of Health's workforce survey data. So we can go to the next slide. Thank you. So transitioning to payer programs, again, we thought it would just be really helpful to give a high level overview of the payer programs, the participation by HSA and the anticipated scale for fiscal year 22. So this slide is really intended to show the scope of programs in terms of those categories. And as you can see, there's four payer programs, or there's four payers, excuse me, with five payer programs, noting that the Blue Cross Blue Shield primary non-risk group does not meet the criteria for scale, as reflected in the third column of this slide. So that's something that will be covered in more detail in the scale section of this presentation. And as shown by the middle column, there's varying participation by HSA depending on the payer program, with Medicaid being the largest program, both by HSA and scale as a result. And we can head to the next slide, please. Perfect. So finally for my section of the high level overview, we wanted to again just give a very, very high picture summary of the income statements. So this is showing two different pieces of one cares budget, the top being the full accountability budget and the bottom chart showing the entity level. So as you can see, one cares fiscal year 22 full accountability budget proposes $1.365 billion in revenue and matching expenditures, which results in a breakeven net income. And the bottom chart, which is specific to one cares fiscal year 22 entity level or gap budget, they're proposing $27.3 million in revenues and matching expenditures, resulting in a breakeven net income. And this is something that Patrick will go into much more detail on in the financial section. So with that, I will pass it, I believe to Sarah. Thank you, Julia. So before we dive into the details, we do want to specifically and explicitly acknowledge the impact of COVID-19 on Vermont's healthcare system generally and on Vermont's efforts to transition to value-based payment more specifically. COVID has created unique uncertainty for providers, ACOs and payers in designing and implementing value-based models. And that includes volatile utilization patterns, impacts on quality measurement, linking results to performance or challenges linking results to performance, as well as financial uncertainty. The, and I want to emphasize minimal silver lining here is that COVID-19 has really laid bare the challenges of fee-for-service payment in this kind of environment and shown us that fixed payments can be a critical tool for stabilizing healthcare providers in times of great uncertainty. Next slide, please, Michelle. Thank you. So we're going to close this high-level overview by sharing a bit about our team's approach to this year's review and the recommendations. You'll notice that the preliminary recommendations have an overall focus on data-driven monitoring and oversight, and that includes a focus on ensuring that the ACOs management drives continuous improvement consistent with the high-performing ACO and that it supports achieving the state's health reform goals. We have shifted away this year from recommendations that are more managerial in nature, and our hope is that by taking a more data-driven approach, we can both reduce the regulatory burden on regulated entities and move the board's focus away from granular line items in the budget, and instead to a focus that is more intently looking at one care's results. Next slide, please. So what does this actually mean? Our core recommendation is to require one care to measure its performance against peer ACOs and to report this to the board. This both gives the board valuable information about how one care's results compare to similar organizations, and it gives one care an important management tool and the opportunity to target their efforts to areas where data shows that there can be root for improvement. It also allows them to learn from high-performers and implement best practices in these areas since they'll have kind of a national peer group. It will also show us where one care might already be best in class, which is important information to know. All of this would be reflected in an updated ACO reporting manual and in the FY23 budget guidance, which would allow us to kind of institute more set benchmarks. So now we are going to move into the key areas of review for FY22, and I'm going to be handing it off to staff to dig into those key areas, but I will just list them for you before we get started so folks have an idea of where we are going. The key areas of review where we'll be digging more deeply in this presentation are ACO certification, FY22 budget and financials, total cost of care and trend rates, payer programs, risk model and settlement, payment models and fixed perspective payments, population health quality and model of care and results to date, and the results to date section includes the federal all-payer model evaluation, all-payer model scale, FY20 payer program results and a recent analysis by Green Mountain Care Board analytics contractor, mathematical policy research. Next up is Michelle Sawyer. Thank you, Sarah. All right, so as previously mentioned, certification is a part of the ACO oversight process overseen by the Green Mountain Care Board. Every year we verify one care's eligibility to maintain their certification. Today, we will cover some highlights from the fiscal year 22 certification process. There is a deeper dive on each section of the certification requirements in the reference slides and there will be additional information in the memo that will be released at the completion of our certification verification process. So earlier in 2021, Dartmouth-Hitchcock health withdrew their membership interest, leaving UVM Medical Center as the sole member. This membership was then transferred to UVM Health Network. When this change occurred, the eighth operating agreement was updated. The ninth operating agreement's primary updates include adjustments from having two member organizations to a single member organization. This reflected or this affected how the Board of Managers is composed, how the Board handles disputed matters, and selection of the chair of the Board of Managers was also updated. With respect to one care's governance, one care Vermont is a manager-managed LLC, which means that it is run by its Board of Managers and not its member. The member's role in the governance of one care is exercised to the member's appointment of three of the managers, which is why we focus on the changes to the composition and structure of the Board of Managers that resulted from UVM Health Network becoming the sole member. The member's direct involvement is limited to the right to approve a sale, merger, consolidation, or liquidation of one care. The admission of another member or changes to one care's articles of organization or operating agreement. We also note that UVM Medical Center provides administrative support to one care, which is not new, but was also the case prior to UVM Health Network becoming one care sole member. One care employees are UVM employees and are covered under UVM's insurance and benefits plan. UVM provides payroll and accounts payable processing and other administrative services to one care. And one care pays UVM and administrative expense reimbursement. These related party transactions are reported in one care's audited financial statements. So previously each member held three appointed seats on the Board of Managers. The three seats previously appointed by Dartmouth-Hitchcock are now redistributed in the following categories. We have one seat for an at-large member, one for an academic medical center in New Hampshire, serving Vermonters, and one for an academic medical center in Vermont, serving Vermonters. As the sole member organization, UVM Health Network may appoint three seats. It is worth noting that the three seats previously held by Dartmouth-Hitchcock must be nominated and voted on by the Board, while the UVM Health Network seats only need appointment by UVM Health Network. Also worth noting the current chair, John Brumsted, is stepping down and leaving the Board of Managers in January of 2022. Theresa Fama of Central Vermont Medical Center Rheumatology will replace Dr. Brumsted as a member of the Board. And the new Board chair will be selected in January of 2022 and will be one of the three seats appointed by UVM Health Network. Our legal team has reviewed the change to the membership and the changes in the operating agreement related to the governance of the ACO and determined that these changes do not violate certification requirements of 18 VSA section 9382A or Green Mountain Care Board rule 5.2. If there are any additional questions about this topic, please feel free to contact the board who is available to provide information on their analysis. So regarding executive compensation, in May of this year, the Board issued guidance regarding executive compensation. The guidance issued by the Board under rule five is a requirement that one care must satisfy to maintain their certification. In order to maintain certification, an ACO must structure its executive compensation to achieve specific and measurable goals or improve the quality and overall care of enrollees or both. Last year during the certification process, we asked one care about how executive compensation is determined. So they shared that they target the market median for base pay and the 65th percentile for total direct compensation through the use of a third party consultant. Staff are gathering information to confirm one care's compliance with the executive compensation guidance separate from this ACO budget and certification process. As part of the fiscal year 22 certification process, the staff have a few remaining questions for one care in the following categories, population health management and care coordination, performance evaluation and improvement, executive compensation and updated and new policies and documents. The staff will be sending these requests for additional information to one care in the near future. The Board does not need to take any action regarding certification eligibility at this time. As in prior years, the staff will be preparing a memo regarding certification eligibility verification for fiscal year 22. Next will be a review of the ACO budget and financials with Patrick Rooney. Thank you, Michelle. If you could advance the slide, please. Great, thank you. So we have two separate versions this year that we're going to walk through here in this review. The first one is one care's full accountability non-gap budget that Julia spoke of earlier. And for those who aren't familiar with this terminology, this is kind of their all-in financial perspective. It captures their expected total cost of care pass through. Contract revenues, including fixed perspective payment and organizational revenues and expenses derived from operations. The full accountability budget is not in line with U.S. generally accepted accounting principles as most of the revenues, mainly around expected total cost of care, fixed perspective payment are the responsibility of third party fiduciaries. So one care when it comes down to it as an organization does not claim those revenues as their own, as an entity. Because of that, we wanted to get a different perspective coming into this year to look at kind of the nuts and bolts of one care. And that's the entity level, oh, come on. Okay, I'm back. Sorry about that. And that's the entity level look that strips away all of these accountability or responsibility components of their budget and just looks at one care of the organization. And when one care is audited, it's done at this level. And that is to take a look at how one care derives its revenue and incurs its expenses to facilitate that larger $1.365 billion budget. We do have an asterisk here that does note that in the November presentation, one care brought about a narrative around a budget of $44.2 million. So this is a separate narrative that one care uses because it's how they see themselves. But it's not part of the guidance that we provided or the review you'll have here today. And the board here will ultimately make its decision on that full accountability version. But we wanted to clarify what the $44.2 million budget that they presented is. And it's an amalgamation of the entity level budget plus the Medicaid next gen added total cost to care, confidential contract revenues, as well as full responsibility for Medicaid admin, traditional and expanded revenues. Now that last piece, the full responsibility, there is a component of that that passes through to that gap version, but it does not pass through on a dollar for dollar basis. So the $44.2 million is really a combination of several factors there. And they're offset by population health and payment reform program and operating expenditures on the other side of the income statement. Next slide please. Thank you. So here we have the summary income statement, full accountability dating back to 2018 to show you the progression in one care as it has come off from kind of its infancy into a more mature organization here as we move from 2021 into 2022. This slide is updated with 2021 projections that we received in their third quarter reporting last week. And there's an asterisk there for the reason that this does include the reporting of about $14.1 million in settlement revenue and $9.6 million in settlement expense. There is on slide 129 a variance table that shows where compared to their revised budget their projection is expected to come in. They are missing their budget slightly except for the areas of other revenues including settlement and population health management including settlement which is where the accounting for that $14.1 million in revenue and $9.6 million in expense is being accounted for. So they are overachieving their budget in those two areas. Also, as you can see the projection, the expectation moving through the fourth fiscal quarter and last quarter of this calendar year is that one carers anticipating a $2.4 million operating surplus to round out the 2021 fiscal year. It's important to note in the 2020 column under net income there is a zero there. This is a topic that will reemerge throughout this presentation today. They did generate a break even budget for 2020. This is due to an action taken by One Care Vermont's Board of Managers to refund the risk-bearing entities of the hospitals in the amount aggregated at $3.1 million. That otherwise would have been their operating surplus for 2020 fiscal year. But if you go to slide 130 as a reference you can see how that refund was distributed amongst the 14 entities, 13 here in Vermont and one in New Hampshire. And we have a breakout by that as submitted by One Care Vermont. The 2022 budget as was noted earlier by Julia is proposed at 1.365 billion. This is a 10.3% increase over the 21 revised budget, 12% over the 21 projection as submitted last week. The major drivers here are increases in total cost of care, fixed perspective payment and participation fees. On the expense side, One Care is also budgeting 1.365, which will result in a break even budget. Major drivers on that side of the equation are total cost of care spend and FPP spend increases. Administration ratios, which has been a metric throughout this process over the years continues to drop as that is weighted against the totality of revenues. So as those revenues grow exponentially if the operating costs grow much slower than that because they were a smaller portion of the total that number will continue to drop. Next slide, please. So as we move through this, we're gonna provide a couple of different perspectives here kind of the traditional numbers table and also an illustration for those folks following at home who are more illustratively inclined. I can understand that. But what you can see here is a chronological financial sequence from 2019 through the proposed 2022 budget of these high level revenue components of One Care. And you can see that expected total cost of care revenue in 2019 was about 43% of total revenues that's grown to 65% as proposed in this fiscal year. Overall, the 884, should it come to fruition in 2022 represents a 200% increase over 2019's actual expected total cost of care revenues. It's important to remember that although One Care is accountable for the expected total cost of care revenue and spend, they do not expend any human or financial capital in processing those claims, but they are accountable for that through their risk arrangements that they have set forth. And the metrics that will determine the outcome of that. Contract revenues have declined as a percentage of total. However, those are primarily driven by fixed perspective payments and fixed perspective payments in 2022 account for about 446 million of that 453.2. Fixed perspective payments in 2022 again, should that tuition represents a 29% increase over 2019 just in the fixed perspective payments category. So there is growth in dollars happening under that line item. Participation fees are also looking to increase up to 19.2 million. Quarter three projections that were supplied to us show participation fees falling about $2.3 million short of that $18.9 million figures you see in the FY21 budget with the date of May 24th. So they are looking to increase that. And as we go back to 20, as we spoke about the refund, you can see participation fees at their lowest point on this table. And the graph to the right will show you the visually, the concentrations of the different revenue components that comprise the financial activity over the years, including the 1.365 billion that is proposed for 2022. Next slide, please, Michelle. This is the other side of the full accountability income statement. You can see here that expenses total 1.365, which results in that break-even budget. The primary drivers this largely reflects the revenue activity on the other side, with that total cost of care healthcare spend growing at a relative amount rising to $875.3 million. And there's that fixed perspective payments spend at $445.9 million, almost a dollar for dollar offset to the revenue growth in that component. One piece here that I'd like to draw your attention to is it will come up as we navigate through this presentation is population health management expenses. Those are at their lowest point on this timeframe and they're lowest point since 2018 in terms of dollars and in terms of percentage of the total. Operating expenses at the very bottom here on slide 26, you can see are being funded at levels relative to fiscal year 19. And we'll talk a little bit more about how one care arrived at that $15.3 million as proposed for budget year 2022. Next slide, please. So for board members, this is a perspective that you'll remember from the hospital budget process for folks who follow exclusively the ACO process. We have not utilized this look yet. This is an effort to illustrate and inform the folks at home of some of the major growth contributors or reductive components of the upcoming budget. And what we're doing here is we're reconciling or bridging one budget year to the next. So we started off on the left hand side there in fiscal year 21 revised budget, which is 1.23 billion for the full accountability. And what are the major components in this category being revenues that are going to get that budget to its proposed $1.365 billion level that OneCare has brought before this board for fiscal year 22. And you can see here that primarily it's a $35 million increase in contract revenues and $91.4 million increase in expected total cost of care. The contract revenue category is driven by the increase in fixed perspective payments moving into fiscal year 22. And that is it for that slide. Next slide, please, Michelle. Thank you. Now we move to the expense categories. And we've broken this down into some of the high level expense categories, total cost of care, phm and operating expenses. This being the expected total cost of care spend moving into 2022, we can see a reductive component to the Medicare modified next generation basic of 11.6 million and then contributing factors to that new FY22 budget for this category, bringing it up to the 875.3 and the major drivers being 16.1 million dollar increase to the MVP program, 36.9 million to Blue Cross Blue Shield primary risk and 46.7 million dollar increase to Blue Cross Blue Shield QHP program spend. Next slide, please. So this one has a little bit more detail. There were a few more categories, all of them important. So we wanted to get it on here. This graph is predominantly taken over by the increase in spend of the fixed perspective payments. So there are some important factors here that you'll see largely around these reductive components coming out of the 2022 revised budget on the left. There are several categories here where spending is being scaled back across population health programs, value based incentive fund being the largest, moving left to right across several primary care provider and primary care prevention activities as well as the innovation fund and large tunnel care. And then on the right-hand side, we have that lump fixed perspective payment increase of 38.6. So these graphs are very helpful in that ordinarily if you're just looking at a variance from year to year you're gonna see a big increase, but by breaking it down visually here, you can see that there is some scaling back of spending in those population health programs by line item. And ultimately the budget for this category increases up to $475 million for fiscal year 22. Next slide, please. So rounding out the full accountability component of this review, we have the operating expenses. As you can see, this is the software and IT salaries and benefits consulting and travel supplies and other. This category is dropping. This category also does comply with generally accepted accounting principles. So you're gonna see this slide again when we go through the entity level version, but for purposes of consistency, we applied it twice. But you'll see that overall from 21 to 22, this budget is coming down about $600,000 and the primary reasons for that is the software IT piece of this at 1.1 million. There's some activity there related to reclassification of expenses and reductions to vital dollars and health catalyst that make up the majority of that reduction. As you can see, the net result of salaries is that they're essentially being level funded with 2019. So there's about a $5,000 variance there, not much movement, but ultimately the budget for operating expenses ends at 5.3 million as proposed by OneCare. Next slide, please. So now we move into this new perspective, the entity level or generally accepted accounting principles based budgeting here. And you can see that when you strip away the accountability that OneCare has, it really boils it down to OneCare, the organization. What drives that $1.36 billion is this right here. These are revenues derived from operations, expenses incurred and the programs that OneCare facilitates from their office. And you can see here that the 2022 budget is being proposed at 27.3 million for revenues and the same for operating expenses, which again results in a break, even budget as proposed. On the revenue side, it's largely being reduced from its 2021 approved budget of 30.2 million due to the loss of HIT and DSR funding, totaling about $3.9 million. And that you can see is occurring in that other contract revenue line item coming from 7.25 down to 3.36. And then there's some offset there with participation fees growing by about a half million dollars from budget to budget. Population health is coming down a couple of million dollars here and then operating expenses about 600,000. So all told, it comes down just about the amount of that, just about the amount of that FY21 value of HIT and DSR funding. Next slide, please. So a similar look to the full accountability to keep it consistent here, showing this chronological financial progression over the years. You can see in 2019, their entity level budget was much, much larger than it is now. You can also see the progression down of contract revenues as those have been whittled away from almost $12 million or $11 million high in 2020 down to the 3.4 that we are looking at now. Participation fees are on the rebound from the low of 2020, but still not as high as 2021. But they do make up the largest portion of this operating entity's revenues. So they are an integral part of what keeps one care, the entity moving forward. And then we do have an increase in administrative revenues related to that Medicare and Medicaid administrative revenues that do transfer through to this gap version of the budget. There's been increased activity. They are both in the full accountability and then in this gap version as well, and those continue to grow year over year. Next slide, please. Here's the expense side of the equation. You can see that operating expenses make up the bulk. And then PHM takes up the remainder of that. So the illustrated chart to the right is not very diverse. These are the two major components of that entity level budget. And we'll talk a little bit more about the population health and operating expenses on the next couple of slides. Next slide, please. So here's the revenue reconciliation at the entity level. We can see that contract revenue piece is discussed as coming down in a significant manner, which is overall suppressing the budget down to 27.3. The bulk of that is related to that DSR and HIT funding. And then we have those incremental components that are adding some back to that potential, but overall the budget potential still comes down to 27.3, but that's that administrative participation fees and other revenues that are increasing over budget 2021. Next slide, please. Here's a little clearer view of the rollback of spending on the population health side. You can see more clearly here, the fact that the fixed perspective payment is not involved in this perspective. The drivers that are reducing population health for programs for one care, the entity, that budget is coming down to about $12 million that essentially brings them in line with pre-2019 levels of investment in that area. So that is going to continue to permeate throughout this presentation, the discussion around population health management and payment reform expenses. Next slide, please. Here's a familiar look, so I won't walk you through it again. These are the operating expenses and the activity that's occurring within that line item and its subcategories there, with obviously a productive component of about $600,000 being the net net between the two budgets. Next slide. Little bit more focus on the entity level total operating expenses. So each one of these categories, you can see the fiscal year on the left and the vertical axes, these all add up to 100%. So in fiscal year 2021, their operating expenses were $15.9 million. So the weights of each one of these categories are applied to the whole and in 2022 is $15.3 million. So the weights are appropriated in a similar fashion. So even though salaries are being level funded, the cuts that are occurring in that software and IT and the reclassification of some of that money to travel supplies and others shifting the weights there. Salaries, if we can go to the next slide, please. A different perspective are being level funded. We can see the growth potential that's occurring there over the years up until 2021. I do not believe they're gonna hit the figures in their projection of that 15.9 million. But as far as comparing budget to budget, salaries are being level funded. And this table here shows you some of the history and the impact of the reclassification that they've adjusted for this coming budget. Next slide, please. So now we're gonna move through a few slides of recommendations for your notes for discussion in the coming weeks. So the first recommendation here on the budget and financials that one carries to notify the Greenmount care ward of any material changes to budget as approved by the one care board of managers, finance committee or leadership include the line item change, the dollar value and the impact of the bottom line is part of quarterly financial reporting according to specifications to be issued in the updated ACO reporting manual. And then there's a staff follow-up there. We really wanted to see this because in some of the responses we got there are certain criteria that allow the board of managers to adjust the internal budget of one care, which means they're expecting a variance either plus or minus. And we feel that it's more efficient to have one care disclose this to us on a quarterly basis than have to try to recap some of that information looking back over almost a full year of activity for that organization. So this is an effort to keep transparency going in smaller blights, so to speak throughout the year rather than to have to try to recap variances looking back in September or October or even now in November and December over a year's worth of activity which can jog the memory a little bit. So we were looking to add that to the reporting manual. Next slide please. The next recommendation is that no later than March 31st of 2022, One Care will provide GMCB staff with the supporting documentation relevant to the topics identified and the condition to be determined among the supporting documentation, One Care must submit final pair contracts, act duration by payer, the revised budget using template provided by the staff, final descriptions of One Care's population health initiatives, hospital dues for 2022 by hospital, hospital risk for 2022 by hospital and payer, documentation of any changes to overall risk model in 2022, source of funds for 2022 population health management programs, update on purchase of approved Medicare benchmarking system for use in 2022, proposed options for benchmarking for Medicaid and commercial payer programs for use in 2023, and any other information GMCB deans relevant to insurance, ensuring compliance with this order. Next slide please Michelle. The next recommendation is that at its presentation of the revised budget and no later than April 30th of 2022 One Care must present the Green Mountain Care Board on the following topics, final 2022 attribution and finalized pair contracts, revised budget based on final attribution, final description of population health initiatives, expected hospital dues for 2022 by hospital, expected risk for 2022 by risk bearing entity and payer, any changes to the overall risk model for 2022, source of sources of funds for One Care's population management health programs in 2022, and any other information GMCB deans relevant to ensuring compliance with this order. Next slide please. The next recommendation in 2022 One Care's operating expenses must not exceed 15.3 million as budgeted and discussed in this review, plus the cost of the benchmarking system to be purchased as acquired in a condition to be determined following approval by the board staff. If the board requires changes to the total amount of One Care's value based incentive fund, One Care may adjust total allowable operating expenses to commensurate with such required changes. Next slide please. In this recommendation, if One Care uses its reserve, adjusts participation fees, i.e. invoicing risk bearing entity for additional fees or refunding fees, or uses its line of credit, it must notify the Green Mountain Care Board of the 15 days of such use. Notification must include the reason for the change for any use authorized under this condition corresponding cash flow analysis. For refunded participation fees, One Care must provide the date of the Board of Manager's decision and documentation of the amounts refunded to each risk bearing entity. Subpart A, the use of reserves, additional participation fees or funds drawn from One Care's line of credit shall be limited to, additional funding for population health investments, financial backing for risk incurred by participating providers, maintaining ACO wide risk on behalf of participating providers, temporary cash flow issues associated with payer revenue delays, and other uses pre-approved by the Green Mountain Care Board. Next slide please. In the last recommendation, One Care must submit its audited financial statements as soon as they are available. They must submit information as required for the GMCB to monitor One Care's performance. One Care must crosswalk submitted actuals per its budget, submission to audited financial statements for fiscal 2018 to 2022. The bulk of that has been done in this past year. And the recommendation of One Care to provide Green Mountain Care Board its most recent version of the ACO's IRS form 990 as soon as it is available. One Care is new to the nonprofit world, but they are working on finalizing their 990. So once that is available, we are looking to make that a recommendation of indeliverable by One Care to Green Mountain Care Board. And with that, I will turn it back over to Marissa. Thank you so much, Patrick. I am now going to talk briefly about total cost of care and trend rates in One Care's budget. This includes projected F by 22 total cost of care by payer and budgeted specific, sorry, budgeted payer specific trend rates. As I mentioned earlier, this is the topic of other board meetings in December. So I'm not going to get into the details today, but I want to introduce the topic. You can go to slide 46, please. So this table is a representation of what is in the budget submission. We have FY 21 projected total cost of care as recently received in Q3 financial reporting, expected budgeted total cost of care for FY 22, that's full accountability and the budgeted trend rates from the base experience as presented in Appendix 4-3 of the budget submission. That is Medicare at 10.6%. That's based on the Medicare call letter that we receive and again, Sarah Lindberg will go into this in more detail next week. Medicaid, traditional 2.1%, Medicaid expanded at 0.7% and the commercial trend rates for the budget year are confidential at this time. There's a note here to remind you that the base year varies by program, the budgeted trend rate does not represent FY 21 to 22 growth and the expected total cost of care for Blue Cross Blue Shield primary is the risk line, the risk lives only not the non-risk or non-scale target qualifying. Next slide, please. So again, getting into greater details, not part of today's discussion, but I wanted to note a couple of key points here that setting the financial targets remains challenging due to the ongoing pandemic and that staff will discuss the implication of the trend rate, particularly Medicare trend for all payer model, agreement total cost of care at the December 15th presentation and make staff recommendations, which I believe is also scheduled for the 22nd. And you can go to slide 48, which is our recommendation on this section. And this is same recommendation or same condition we have used in the past, which is that one care must ensure that it's payer contracts are consistent with the following 2022 benchmark trend rates in related conditions. So for Vermont Medicare ACO initiative, it's the trend factors proposed by the GMCB and approved by CMS that is happening shortly for Medicaid Next Generation ACO program. It's the trend factors that are consistent with the approved Medicaid rate and the GMCB's recommendation in the Medicaid advisory rate case. And then for the commercial program, the benchmark trend rates for commercial programs must be consistent with the ACO attributed population and the GMCB approved rate filings. And also to help verify these trends, one care must provide the GMCB with actuarial certification for each of it, commercial benchmarks and an explanation of how its overall rate of growth across all pairs fits with the overall APM target rate of growth. And if its overall rate of growth exceeds the APM target, how it plans to achieve the target for the term of the APM agreement. And then they submit a revised budget based on the finalized benchmarks in the spring. So this recommendation or sorry, condition has not changed since last year. And Sarah Kinsler is going to continue with payer programs and risk model. Thank you, Marissa. Now we're gonna dive a little bit deeper on payer programs and the risk model. We know that this was an area of significant interest in last year's process. And so we hope that this year we can, you know, give a little bit more information and analysis. I'll be giving a summary of the risk models in each program talking about total risk by health service area and how the primary care about accountability pool fits into that risk. And giving a summary of the policies related to distributing shared savings or shared losses that OneCare maintains. So on slide 50, we've included just a bit of background to level set. So OneCare assumes risk from payers and then it designs and implements the methodology for spreading that risk out to the provider network. This is documented in OneCare's policies and its agreements with providers, but we kind of wanted to separate those two concepts and we'll talk about them a little bit separately. So slide 51, it's just a brief disclaimer. This analysis is based on the budget submission only because the contracts are still in process. Medicare and Medicaid contracts are finalized by the end of December and are required to be in effect for January 1st. Whereas on the commercial side, the contracts are often not finalized until after the start of the performance year and are presented in their revised budget submission presentation. On slide 52, the slide covers the first aspect of that background slide. So this is the risk that OneCare assumes from payers. And I won't read the slide to you in detail, just to note that it reviews key aspects of each payer program, including core payment models, budgeted risk corridor, noting that that information is confidential and redacted for commercial programs and the link to quality. I'll note that the submission is not particularly detailed about the link to quality at this time. These statements come from the submission and we expect to receive more information in our review of the finalized contracts. So before we move on, I'll speak to the risk corridor column, just to note that these risk corridors are fairly consistent with FY21, but that that is a pretty steep drop from earlier years of our review. For example, in 2019, the board's order set maximum risk limits at 5% for Medicare or 4% for Medicaid, 3% for commercial and 1.8% for self-funded. And obviously COVID has significantly impacted those risk corridors, but that's just something that we wanted to highlight. Moving on to the next slide, I'm going to shift to talk to me about how OneCare then distributes that risk to its network. This slide and the following slide cover key OneCare policies. So the program settlement policy here describes the $1.50 per member per month payment or excuse me, first dollar kind of risk and potential for savings for primary care practices. After this first dollar amount of savings and risk, OneCare subtracts any funding obligated to cover OneCare's expenses as approved by their board of managers. And then 90% of the remainder of that amount is distributed to each health service area's risk-bearing entity, also known as the hospital, while the other 10% is allocated to a performance incentive pool, which we describe a little bit more on the next slide. Finally, savings and losses are allocated based on HSA level attribution. So it's proportional to the population. On slide 54, we give some more detail about that primary care accountability pool as well as the performance incentive pool. So on the primary care accountability pool, practices can either pay into the accountability pool throughout the year as a withhold from the base per member per month that OneCare distributes or elect to receive an invoice from OneCare at settlement if the ACO is required to pay back shared losses. And this was a hot topic in the FY21 review. The projected total of the primary care accountability pool for this year or for the coming years, 2.4 million, that's 15% of total risk. And then the current policy is for FY21. So we just linked to the policy name there. On the performance incentive pool, that sets aside 10% of the total savings, if there are any, to reward HSAs that perform particularly well on two measures that OneCare has decided are core measures. And that's per capita cost and avoidable ED visits. It distributes the savings or I guess the performance incentive pool portion of the savings based on the accrual of PIP points. The current policy is also FY21. So on the next slide, this fairly unreadable table and slide form shows how the risk is distributed by health service area and within health service area by provider type, showing the primary care accountability pool as well as the risk bearing entity share of risk. I do wanna note that the FY21 percentage column is not some here because of rounding, but really the key takeaway is that as previously mentioned, primary care holds 15% of the risk and 7% of that is hospital under primary care. So this just gives you a sense of kind of how that plays out across the state and by primary care and hospital. So on slide 56, board members and the public may remember that a significant topic of discussion at last year's presentation was the change in the risk model from the HSA-based risk model to the network-based risk model. And we wanted to do some analysis to see how that played out. This slide just summarizes the changes. In the HSA-based risk model, the HSAs were basically treated as many ACOs with their own total cost of care targets. Now the ACO spreads out that risk as we've described on prior slides to the whole network based on the population size. Shifting from the HSA-based risk model to the network-based risk model was intended to increase collaboration across the network. Participants, the hospitals might have more incentive to look outside their HSA for the most efficient care setting. There also might be increased motivation for the ACO to identify and lead strategic planning for system-wide cost control. The network-based risk model also decreases year over year volatility associated with small numbers since some of our HSAs are so small. But we really wanted to see how that played out across the state. So in the round one questions that staff issued, staff requested that one care provide an analysis of the 2019 performance, shared savings and shared losses distribution and look at that both based on how it was actually distributed according to the HSA-based model and how it hypothetically might have been distributed using the newer network-based risk model. The goal was to identify winners and losers for lack of a better term under the risk model now in use. So slide 57 repeats some of what I just said verbally, but we really wanted to play out the new policy. So on slide 58, we have included this analysis. I want to highlight that negative numbers on the slide are savings and positive number are losses. The key takeaways here are that the HSA model with its individual HSA total cost of care targets created some big winners and losers. There's significant variation in savings or losses across the network. In the network-based model, this really gets smoothed out. So rather than a mix of significant savings and losses, we end up with generally modest savings for most HSAs. We've also flagged in a very kind of simplistic way whether each HSA fair is better or worse under the new model. But I do want to note that this is specific to 2019. We don't think that this would necessarily track to future years because the HSA-based, in part because the HSA-based risk model is so volatile and based on really small numbers. Slide 59 puts this into words and provides those key takeaways again. There are pros and cons to decreasing that volatility across HSAs. We think that decreasing volatility due to the small numbers is a big pro in our state where some communities are really small. The con here is that smoothing out savings and risk across HSAs means that incentives are weaker for participants since the total savings or risk is more modest for most communities and pretty small compared to hospitals' total budgets. So on slide 60, this brings us to 2020. The financial results from the 2020 payer programs were presented on November 22nd along with the quality results. And we'll talk about that a bit more later in the presentation. I have listed the total amounts here. I want to make an important point that these FY 2020 settlement amounts do not go straight to One Care's bottom line. There are policies in place, the policies that we reviewed earlier, which outline how One Care distributes any shared savings payments that they receive at settlement. This policy, the current policy gives the One Care Board of Managers the opportunity to choose to utilize that some portion of that shared savings received at settlement for other purposes, but in general it's outlined pretty specifically in those documents already. So to wrap up this section, our key takeaways are on this slide. The total budgeted risk and reward is $16.2 million for FY 2022. A pretty solid chunk of this is linked to the primary care accountability pool, $2.4 million in total. That includes $1.3 million from non-hospital primary care. And we've also summarized the network-based risk model, of which we talked about in depth just a moment ago, as well as the performance incentive pool. So staff have two recommendations related to payer programs and risk. The first is a condition which is consistent with past years, that payer programs must be designed to be scale target qualifying ACO initiatives as defined in the all-payer model agreement to the greatest extent possible. And I will not read the full recommendation unless that's the board's preference. And then secondly, on the next slide, we have another condition that is also consistent with past years. And that is to require One Care to implement the risk model as described in their budget and to submit documentation of this and seek approval before making changes to the risk model. The ACO reporting manual would also be updated to reflect some related reporting as well. Before I pass it back to Marisa, I do wanna note that previously we had a related condition that outlined maximum risk limits and set them in line with contracts. In FY22, as I mentioned earlier, risk is lower than those past maximums. So this is something that we haven't included in staff recommendation this year since it does not feel as necessary. But it is something that we could consider addressing in fiscal year 2023 guidance if the board was so inclined potentially by requiring comp payer contracts to reflect minimum levels of risk if the board deans that appropriate. So that is all for payer programs and risk. And I'm going to hand it over to Marisa. Thank you, Sarah. I'm going to talk now about payment models and fixed perspective payments. So it's gonna break down that large number that Patrick was talking to earlier. I wanna start by highlighting this diagram from the recent federal evaluation of the all payer model that was presented by the NORC of the University of Chicago on November 5th at one of our board meetings. Because I think it's a nice representation of the funds flow in the model in the role of the ACO arrangement. So the ACO, which you see in the middle of the diagram negotiates agreements with the payers who are at the top of the diagram on behalf of their provider network, which you see on the sides, both hospital and primary care and non-hospital providers. And one care serves as the program negotiator and allows the ACO to design, implement and operationalize alternative payment mechanisms that would otherwise have to be negotiated individually by hospitals or other providers absent the ACO. The ACO is also able to redistribute funds on behalf of the network toward population health management and reform programs, which you see at the bottom of the diagram. And those benefit the entire network. And in some cases, as noted in the evaluation, the total population. So recent discussion of these payment mechanisms at this board and in the agency of human services, all payer model implementation improvement plan have focused heavily on implementation of fixed perspective payments. Also called CMS upfront payments or Medicare, all inclusive population based payments. Also referred to as fixed perspective payments that are reconciled to fee for service. So there's a lot of terminology being thrown around here. I wanna focus a little bit on these models in my next couple of slides and what we see in the data at this time. So you can go to slide 65, please. So one cares fixed perspective or fixed payment models consists of these two buckets. There are fixed perspective payments to hospitals, which consists of the Medicare, the Vermont Medicare arrangements, the all inclusive population based payment, which is reconciled to fee for service, the Medicaid fixed perspective payments, which are unreconciled and then the Blue Cross Blue Shield fixed perspective payment pilot, which is also reconciled. There's also the comprehensive payment reform, or often referred to as the CPR program to independent primary care. And this is a pair blended fixed payments for independent primary care practices for core primary care services plus additional PMPM for non-core services. We have a more in depth report on the comprehensive payment reform program as requested by the board, but I just pulled out some very high level numbers here. So the total CPR payments that were projected or that are projected for fiscal year 21 are a total of $6.9 million. So this is the total amount that consists of contract money through the payers. And then there's a one care funded share, which in FY 21 was 1.2 million. So the 1.2 million that you see in one cares financial sheets is the share that's invested by one care at their entity level budget. But the bulk of the pair blended payments are derived through the pair contract, which is in the full accountability budget. And again, that FY 21 total comes from the CPR report that was submitted by one care in July of this year. I do not have the total budgeted payments for the CPR program for FY 22, but it is included in that FPP CPR line item in the financial sheet, which you'll see on the next slide. The one care funded share did increase slightly in the FY 22 budget to 1.3 million. So on slide, right there, slide 65. This is our analysis of fixed perspective payments as a percent of expected total cost of care. This is for the 22 budget. And we also included what are known as the HCP LAN category. So HCP LAN is the healthcare payment, learning and action network. The HCP LAN sets the framework that we referenced for national measurement of payer program penetration of alternative payment models. The HCP LAN publishes an all-payer model framework that defines levels of alternative payment models from anywhere from fee-for-service with no link to quality or value up through the spectrum to comprehensive population-based payments or global budgets. I'm not gonna go into a deeper dive on HCP LAN framework, but wanted to reference it here in the slides. If you want to take a look at that framework, we included in the reference slides at the end of this deck, slide 136. I will note that these categories are not perfect to Vermont's arrangements, but this is the best framework that we have to provide us a national comparison. And we have used it since the inception of the model. I will also note that there's not one way to design these models. The goal here is to link payments to quality and value, but not all the arrangements have to be a category four in order for this to work well. So I'm gonna talk about the table a little bit. We used average attribution in this table, which are, again, estimated average numbers that OneCare submits that are used to set their budget because, as we know, attribution drops off over the year. So if you use January one or scale attribution for these estimates, then they would be over budgeting. But I included these here just to give you an idea of the magnitude of each program. Staff took the FY22 budgeted figures for expected total cost of care and fixed payments to calculate the total fixed payments as a percent of expected total cost of care. And then we categorized them by land category. So the results here are that over 50% of payments in the public payer program are considered category four B arrangement. Now I wanna make a note about this because I know that there's been much discussion about which category these payer programs fit into. So we looked into that and found that. So what happens is payer programs report to the HCP land, I think as frequently as annually on what type of payer arrangements are and what categories they fit into. The Medicaid program reports their fixed perspective payments as four B and we check in with CMS Medicare and they confirmed that the Vermont Medicare all inclusive population-based payments are also reported as four B even though they are reconciled to fee for service. So we did include them in this category. So I've made a note about the difference between reconciliation and unreconciliation because that's been a significant point of discussion in the state. And as has been discussed by the board before, commercial, the commercial program, as you can see here is far below in this category at 1.1% overall, we blended the commercial together because some of those figures are proprietary or still subject to negotiation. And the categories for the Blue Cross Blue Shield and MVP programs we collected through the rate review process. And they, that the Blue Cross Blue Shield pilot as our understanding is category four B reconciled. The Blue Cross Blue Shield QHP, they reported as a category three B and MVP which is shared savings only is reported as a category three and then overall 34% of payments in the full accountability budget are, obviously these are weighted by payer program are in one of these categories. Another thing that I wanna note here is that there's a component of the payer contracts in the CPR and I am not sure if this is captured here. So we do need to work with one care to make sure that what we've presented in this table is accurate, but this is our best understanding at this time with the numbers that we have. Validated reporting on fixed perspective payment and CPR is part of the recommendation in this section. I know it's also a topic of conversation in the hospital budget process. We're trying to make sure we have accurate reporting on the percentage of fixed perspective payments by hospital. You can go ahead to the next slide, which is 67 and this slide summarizes the report that one care submitted to the green mountain care board this summer as required in the FY 21 budget order. Again, these are one care developed tables and baselines and targets. So I still think we have some data validation that needs to happen, but this is what they reported to us. Cable one is the percentage of contract revenue in fixed perspective payments. Now this is for the baseline year, which we chose as 2019, a pre-pandemic year. You'll see that their numbers are really different than the ones I have and that's because the Medicare is not, one care did not include Medicare in the FPP because they were interpreting it as, or maybe even at the time we all were interpreting it as because it's reconciled to fee for service that didn't fit into that true fixed perspective payment category, but we have since got more information that that's, well, there's some discussion around it, but that's not the accurate reporting according to HCP land. So they're reporting zero where we are reporting much higher. Our Medicaid numbers are fairly on the line. Again, we're talking about two different years, but they still are in line. And then commercial, again, there's a small percentage that is in there, though not for the baseline. Cable two are the targets and milestones for contract revenue in fixed perspective payments from the baseline and then through to fiscal year 25. So if we were to just take these numbers as presented, you can see that for Medicaid and Medicare were already there for their targets with though they talk about our one care discuss strategies for some continued growth in these programs, particularly Medicare, essentially the Medicare line in the one care report represents what it would look like if we were able to convert those reconciled to unreconciled payments and some modest growth in Medicare program, I believe. And then Medicaid again, shows some growth, but we are already hearing those targets. The targets for commercial, as you can see, they estimated a target for 22 at 2.9. As far as we could tell, we're not at that number for 22. Again, this was done over the summer while the budget was still being developed. Our analysis, it looks more like it's still around 1.1% overall for commercial. And then there are some pretty ambitious targets there from for 23 through 25. So I want to make sure that hit the main points here. Okay, so my fourth bullet point there, that the ambitious targets for FY 23 through 25, the strategies that one care discussed in their report is increasing hospital fixed payment programs, increasing inclusion of FQHCs, and increasing the CPR program. I'll note that by magnitude, the first one there, hospital fixed payment programs, is where they think the greatest magnitude of the impact can come from. So I'm gonna leave it at that and go to the next slide, let's have some key takeaways about the analysis as far as we can tell at this time. So in past years and in other regulatory processes, Greenmount Care Board members have indicated a desire to move more of Vermont's healthcare spending to fixed perspective payments, increasing fixed perspective payments, and in particular, unreconciled FCP requires regulatory action across processes, changing the Medicare payment model requires continued partnership with Medicare and providers, and progress on one care's ambitious targets, especially for the commercial program will require continued monitoring and reporting. So there are some, well, there are, sorry, there are not recommendations. You can go to the next slide, Michelle. And by recommendations, I mean, there are no recommended budget conditions at this time, but we do have some next steps which are already in process on this issue. So as previously instructed by the board, the Greenmount Care Board staff are to continue to engage in rulemaking, or sorry, in rule development as a precursor to formal rulemaking process for a new rule to increase FPP with potential rule to span GMCB's ACO oversight, a hospital budget review and health insurance premium rate review processes. So we've determined in our analysis that making some kind of, we can't just order a condition that one care increase these numbers, it has to span regulatory processes. So it includes work with the insurance and the hospitals or through hospital budget review authority. And the first step is that we have engaged for the contractor on options for how to pursue this. The second bullet which I touched on is that in FY22, the staff developed reporting templates will better capture payer ACO payment arrangements, provide guidance to one care and where current payer ACO payment arrangements fall in the land framework and require reporting of reconciled FPP and unreconciled FPP separately. So we've already started this work on how to better capture and make sure that we have consensus on the reporting around this. And we will continue that work through the year. And I think that concludes this section. And we're gonna move on to population health quality and model care, which I'm also going to introduce for you and work with Michelle and others because this is a large area of review. So this section seven of the budget itself is quite large. It includes ACO quality, population health, model of care and community integration efforts. And what we're gonna talk about today are major programmatic and budget changes that we're seeing in FY22, population health quality related payment changes and the clinical focus areas and VBIS priorities. For some background, we've used these slides last year to frame this section. This slide is meant to boil down the seven criteria that most applicable to review of the ACO's model of care and population health programs. On the left, the criteria requires that board members review and consider these three major buckets. One is incentives and resources or we can call those payment changes. Two is information or data and three is efforts or tools. So we think of the review of this section under these budgets. On the right, the criteria call out these priorities specifically. They are to strengthen primary care, to integrate with community-based providers and the blueprint for health. For example, mental health and substance use disorder, which is called out specifically in the criteria to address social determinants of health and the impact of adverse childhood events and the effects on appropriate utilization. Slide 72, please. This is just another look. The circles here represent the three budget, sorry, three buckets that the criteria fit into. In the boxes are examples of core competencies of the care model that are identified by one care in their narrative. I use this graphic as a simplified crosswalk of how one care states their own core competencies and how they align with our review criteria. You're going to hear more from this soon, from our consultant, Joe DeMore, who's on the line, including his recommendations to one care on how they can strengthen performance in these areas, using his expertise as a leader in integrated health systems and high-performing ACOs. And then you'll also hear from Joe on his regulatory recommendations to the board. And I believe now I'm going to pass it to Michelle DeGree, who is going to continue with the discussion of the more detailed program changes in FY22 and the recommendations. Thanks, Marisa. I just want to clarify that everyone can hear me okay. Okay. So as Marisa mentioned, we're looking at the most notable changes here, so ensuring that the staff are bringing to the board members and the public for consideration, just what we sort of honed in on as high priority areas that have changed the most significantly. So as you see through the bucketed categories on the screen, we have the Value-Ace Incentive Fund, Rise Vermont, Care Navigator and Care Coordination Payments. I sort of think of the last two sort of together, but I'll talk through them a little bit more in detail. So under the Value-Ace Incentive Fund, as you can see, it was reduced or it's proposed to be reduced in the 2022 budget. It's down to one million. It was 2.24 million in fiscal year 2021. I think that something to call out here from one care submission is that the intended focus of the 2022 program is in alignment with the current 2021 program with respect to the provider payment structures and the focused quality metrics. So I'll talk about those in a little bit more detail later, but One Care continued with its four quality metric program in the VBIF space from 2021 into 2022 just to allow for some more continuity there. Under the Rise Vermont program, I'm sure you recall from One Care's presentation, Rise is phasing out in 2022. So it's funded for the first half, the first six months of 2022. And One Care sites this as a shift from community-based to clinical prevention model. Under Care Navigator, documentation requirements in Care Navigator have become optional. So use of Care Navigators no longer required to receive those Care Coordination Payments. I will add that One Care stated that it's working on alternate reporting modalities to its network. So if Care Navigator is not being used by everyone, they're working on sort of developing and thinking through ways to still get that information out to their network. Under the Care Coordination Payments, so again, sort of tying back to Care Navigator, One Care's decoupling Care Coordination Payments from the use of Care Navigator. So this change reduces the maintenance costs of that overall Care Coordination System. Of note, payments are now tied to total cost of care and other metrics, which are still likely to be tied to total cost of care and other metrics, which are still to be determined. So some things that One Care mentioned in its narrative were things like measures such as change in total cost of care, avoidable ED utilization, and inpatient utilization are areas of example of focus with clear correlation to desirable total cost of care and quality outcome. So just sort of trying to tie that back to overall improvement of health in their space. Michelle, you can go to the next slide. So as I mentioned earlier, well, just about 30 seconds ago, Population Health, the Value-Based Incentive Fund. So again, the proposed amount there is a million dollars. These are the four clinical focus areas or VBIF priorities that remain the same in the proposed 2022 budget. I will try to use one term, which is VBIF, but of note, they are the same as One Care's clinical focus areas. So those four measures are also the clinical focus areas of the network in 2022. Those areas remain steady. So again, diabetes, hemoglobin A1C, controlling high blood pressure, early childhood development and screening and depression screening and follow-up. One thing to just point out here is the very close alignment with the all-pair ACO model metrics that we are, the state is responsible for reporting on behalf of our agreement with CMMI. And with that, I'm gonna briefly turn it over to Patrick for a couple of slides before we come back for some staff recommendations. Thank you, Michelle. So what we have on slide 75 is a snapshot of the Population Health and Painting Reform and Investment Activity over the last several fiscal cycles here, ending with 2022 budget proposal. We have a 3.5% increase from projection to budget in blueprint programs. You can see there that since 2019, there's been an increase year over year in those investments rising to $9 million in fiscal year 2022. In the Population Health investments, we have a 3.9% increase in the overall component of that from projection. However, we're to compare it to the $30 plus million they originally budgeted for 2021, they're actually coming down about 4%. So that means they don't intend to hit their 2021 original budget figure. And so the 2022 amount of almost $29 million falls right in between the projection that we see here on the screen what they budgeted, which was $30 million plus for 2021. So it's kind of a dueling narrative there that it looks like it's an increase over the projection, but it's really a reduction when we look at the budget to budget perspective. PHM revenues as a percentage of total have declined since 2019. Some of that has to do with the fact that that measurement is weighted against the total. So you can see between 2019 and 2020, the total revenues just about doubled, which is a pretty substantial increase when you think about the dollars that are passing through this organization. So it's not that, I mean, the dollar component of Population Health has fallen, but in proportion to the growth that we've seen in total revenue, it's driving that percentage figure down. And as the next bullet points to total revenues between projection and budget are rising about 12% as proposed here today. Regarding the PHM investment, there is no benchmark for the right ratio. The programs don't tend to scale up at the same time or at the same rate as attribution does. Next slide, please. So here's a little more granular detail. Again, that chronological sequence over time. If we look at 2019, we have in our midst there growth potential of these investments and that one care is investing money into Population Health programs. We're seeing that pretty substantial leap from year to year, 2018 to 2019. It's also the last pre-pandemic year. As we walked through the hospital budgets, we noted that quite often. So when we look at that growth potential year and then where we're going in 2022, we're seeing a couple of different components occurring here. One is that blueprint programs are remaining strong. We just saw that. The investments are growing. They've grown 13% from 2022 or 2019. And also the Population Health Management Payment piece has increased 77% over 2019. Now those two components make up 64% of your fiscal year 2022 PHM budget. So if those remain strong or they grow, they're gonna prop up the total $28.3 million investment that's being made. So they're about $18.5 million worth of that total spent. But if you look at some of the other pieces here as they're color coded specifically, looking at that green chunk in 2019, the third one up from the bottom, that's your VBIF. And you can see over time here that the investments there are being squeezed. And as Michelle noted, it's about $2.5 million in the prior year. It's now down to $1 million. So we're really seeing that investment kind of trickle off after that growth component in 2019. Complex care program is down 34% since 2019, going into 2022. The VBIF piece contributes an 87% reduction from its 2019 comparable. So there's a lot of activity here where investments are kind of being whittled down in the population health piece. CPR program is 41% lower than its 2019 comparable. And there is no funding for PCP engagement incentives in 2022, either Blue Cross or Medicaid expanded. So we are seeing a reduction in a variety of these programs. But again, they're being propped up by the strength of the population health management payment and the increased blueprint investments, which again, make up about 64% of that total figure you'll see in 2022. So Michelle, I'll turn it back over to you. Thanks, Patrick. So for the largest section, we tried to keep it pretty small, but that also means you're about to see a handful of recommendations. So key takeaways here, again, value-based incentive fund being reduced. We've got changes to the rise per month and care navigator platforms and care coordination payments. And that results in a total reduction in the PHM category of expenditures of about $2.8 million. Michelle, if you could go to the next slide. Thank you. So starting with some recommendations here, I'll speak to all of the ones we have under this category. So the first one that you see in front of you, and I will say slide, I wanna make sure folks who are on the screen, 78, if you are following along, is a carryover from fiscal year 2021 budget order. So this is just asking that one care fund the budget as proposed. And if any changes or PHM programs and reporting change by the one care come back and let us know with their revised budget submission. So again, by the end of quarter one, 2022. Sorry, I've got a lot of years in my head. Michelle, if you go to the next slide. Our second recommendation, again, this is one that we've had for quite some time now. So in 2022, we're asking one care fund in the amount that you see on your screen there, which is the budgeted amount plus an inflationary factor and the same for the blueprint for health to just kind of sum that up for you. So you don't have to do the math. Once you trend those 3.5%, it's $9,073,982 total that we're asking them to put into that bucket. This is what one care proposed in their budget. And staff recommends that trend be accepted. So if we can move to the next one. Thank you. So our third half recommendation, future recommendation is around the VBIF. So as you sort of heard me talk about, the staff here are really expecting to recommend an increase above the budgeted amount of a million dollars. We need a little bit of additional time to sort of work through some information that we've received and making sure that we are really setting the board up with the best information possible to be able to make that recommendation and potential budget order condition. And so we, as you heard earlier, are proposing to come back to you next week with that recommendation. And just a reminder, sort of under there on the considerations, you see that in the past, the VBIF has ranged anywhere from four to six and a half million dollars in prior years. And you saw that in Patrick's slides as well, you saw that detailed out. So just sort of the basis for our sort of thought process around making sure that the staff are recommending that we think that should be increased. And then Michelle, you can go to the next slide. This is our last population health recommendation here. Our fourth and final recommendation here is another carryover. This has been included in some aspect, some level of detail since 2018 budget order. So this is the first one. I have all of the conditions listed out if you want to know what they are, but I won't go through them now, just to say that this has been included since 2018. And so again, we're asking one care's administrative expenses to be less than the healthcare savings. And with that, I believe I turn it back over to Sarah Kimbler. So before you do, Michelle, I've had multiple requests for a bio break. Okay. I thought that we could get through the staff presentation, but it's clear from the text messages that most people cannot. So I think this would be a good time to take a bio break and we'll resume in 10 minutes at 2.52. So Kara, if you could put something up on the screen that just lets people know that we're on a bio break to 2.52, it would be great. Thank you everybody. This meeting is in recess. So we have all the board members back. I'm going to call the meeting back to order. And Michelle, you were in the process of handing it off to Sarah. So. I was. Thank you, Mr. Chair. So now we are going to move into presenting results to date, which will include some results and analyses related to the all-pair model, as well as specific to ACO performance. This slide tries to kind of distinguish between these, but also note that they definitely inform each other. So on our next slide, we've just got a list of the results that we will be, we'll be speaking to today. The first is results on the federal all-pair model evaluation by NMRC, results on all-pair model scale targets, ACO 2020-pair program results, which we already covered a little bit and then an analysis done by the GMCB's all-pair model analytics contractor, Mathematical Policy Research. So I am going to speak to the federal all-pair model evaluation. These are the findings from the first report that has come out of the federal government's evaluation of Vermont's all-pair model. The results were presented to the board on November 5th, and on the next slide, there's a link to the Green Mountain Care Board staff slides, as well as the slides that NMRC actually presented at that meeting. By way of introduction, I'll just say that the Vermont all-pair model, like all federal demonstrations, is required to be evaluated. NMRC, a national firm that has extensive experience in health services research, and specifically in evaluating state demonstration models, like the all-pair model, was hired by CMMI for this job. We want to note that Medicare is the key focus of this evaluation, though it does also consider the wider impact as well, and you'll see that evident in the report if you review it. I've linked to the report itself, as well as the summary of the report and all the technical appendices on this slide for easy finding. So the next slide covers some highlights from the key findings from this report. I do want to note that this is not a totally comprehensive list, and obviously does not go into detail, but these are kind of the things that we picked out as most relevant to this conversation. So in the first box, the report shows statistically significant Medicare spending and utilization reductions, both for the Medicare-ACO program and for the full Vermont Medicare fee for service population relative to a comparison group. This is an area of where there's been a lot of kind of conversation and confusion. I do want to note that these spending reductions and all of the results in the report are not in comparison to past Vermont performance. The report methodology compares Vermont to a comparison group rather than to Vermont's baseline performance, and so the results can reflect complex trends, including trends in the intervention group, Vermont and the Vermont ACO, or in the comparison group. This is not always clear, but it's something that we really want to make sure that folks understand. In the next box, the qualitative findings include improved cohesion around shared goals and collaboration across the state payers and providers. The report also found spillover effects, which I kind of alluded to on the prior side, to the full Vermont population, noting that some of the ACO and hospitals population health initiatives are pair blind and serve ACO and non-ACO beneficiaries alike, as well as that Vermont has a long history of investment in primary care and population health, statewide culture of reform and strong regulator in the Green Mountain Care Board. All of these things kind of add complexity to this evaluation, and may help explain why we're seeing benefits at the population level. In the next box, the evaluators did find a lack of widespread understanding of the model, a perceived lack of transparency, and some distrust that have all contributed to challenges in needing practitioners and the public in the model. And then finally, the report found that transformation will require more comprehensive transition to value-based payment and focus on upstream investments that address social determinants of health looking forward. So I've again linked to the slides from the November 5th presentation here, and now we are going to transition to discussing all-pair model scale, and I'll be handing it over to Russ McCracken and Michelle DeGree. Great, thank you, Sarah. This is Russ McCracken, staff attorney here with the board, and I'm gonna go through here the requirements in the APM agreement for scale qualifying ACO initiatives. This slide here sets out the requirements there from section 6B of the agreement, and I'll walk through them here. The first is that the arrangement has a possibility of shared savings for achieving goals related to quality of care or utilization. Shared savings being monetary amounts owed by the payer to the ACO. The second requirement sets out some criteria for the shared savings and if applicable, shared losses. So the shared savings as a percentage of expenditures less than the benchmark is a minimum of 30%. If the arrangement also has a shared loss, then there's a similar requirement there for it, but the baseline requirement here is that the arrangement has shared savings and this section doesn't indirectly add a requirement for shared losses. Third, the arrangement has to have services comparable to a defined set of services in the APM agreement, and those associated expenditures are included in the determination of any shared losses and shared savings. And finally, the ACO's benchmark shared services, shared losses or a combination is tied to the quality of care that the ACO delivers and or the health of its aligned beneficiaries. So next slide, Michelle. To kind of summarize it, the main points here that to be a scale qualifying initiative, the arrangement has to have the possibility for shared savings, but does not require shared risk. Really what we mean here is that it doesn't, the arrangement doesn't require the possibility of shared losses as a necessary element to be a scale qualifying ACO initiative. For example, the Blue Cross Blue Shield primary non-risk cohort is a cohort that doesn't participate in either shared risk or shared savings. So it would not be considered a scale qualifying ACO initiative. The next requirement, they said there's a 30% minimum a share of the shared savings or risk corridor that goes to the ACO in a clearly made up example here to illustrate with some fictional dollar amounts. If a program's total cost of care target was $1 million and had a contracted corridor of 3% either upside or downside of that total cost of care, then the ACO share of that shared savings has to be at least 30% of the 3%. So we get to about $9,000 in that illustration. As I mentioned in the previous slide, there has to be alignment between the arrangement and the services included in the total cost of care target with what is defined in the APM agreement and it's fairly comparable to Medicare's part A and B. And lastly, the financial components have to be tied to quality and or health outcomes. Next slide, Michelle. Great, so with respect to the process, the GMCB and staff receive some kind of basic information about each payer contract that they anticipated for the following year as part of the ACO's budget submission. The contracts aren't final, but this provides a bit of an early look for us at what's expected to be included in those contracts. With respect to timing, the Medicare and Medicaid contracts have to be executed by December 31st. So we have those at the year's end, though not always in time or during the ACO budget review process. The commercial program contracts are typically signed in the spring of the program year. Once the payer contract is finalized, GMCB receives a copy, reviews it, focuses on changes from prior years and checking it against the requirements for a scale target initiative. And once we've done that analysis, that gets incorporated into the report that the board sends to CMMI in the summer of each year. And with that, I'm going to pass the presentation over to Michelle. Thanks, Russ. Okay, so kind of looping back to what Russ just said and wanting to give the board an idea of projections for fiscal year or performance year five, which is calendar year 2022. So the slide that you're seeing is estimated scale based on current information that we have available to us. I can't emphasize enough that this will change. Final 2021 results will be incorporated into the 2021 scale target and alignment report, which is due in June. The report that Russ just alluded to. And again, something to point out here for both 2021 and 2022 is that we're not meeting those quite ambitious scale targets, which were recognized by CMMI as unattainable. We are, however, making some progress in the all-payer space, thanks in large part to some growing commercial attribution. So again, a couple of caveats here being that currently the 2021 and 2022 data are utilizing 2020 population estimates. That's how we get to our final calculation. So that will be updated with the 2021 scale report given that at that time we'll have 2021 estimates. And to note that the numbers that you're seeing here, what I have included for counts are the numbers that I've received directly from Medicare and DEVA for their prospective attribution estimates. So those two numbers, you'll see them again on a couple of slides, might not directly match with what was in one CARES budget, but are the numbers that we ultimately include in scale. So I wanted to try and keep that consistent throughout the process. So Michelle, you can go to the next slide. Thank you. So here again, you're seeing the first two rows there are those prospective tar estimates, but it come directly from the payer. Just wanted to sort of break scale down a little bit more for you and give you another look at scale. Obviously here we're looking by payer type. And again, 2021 and 2022 will change with that updated population estimate and with updated payer contracts once those are final. So specifically in that commercial space. So we've broken this out by fully insured and scale qualifying self-insured. So this would not include any of currently only Blue Cross offering any program that is not scale target qualifying. Michelle, you can go to the next slide. A third and final look at scale here. So this is sort of the deepest dive that I'll give you into payer contract scale. Again, this one really specifically calls out that non-scale qualifying group in that Blue Cross Blue Shield space. It's the great out row. If you do the math that number does not count towards that commercial sort of bolded row there. Again, lots of caveats here. I think you'll see we've got six footnotes just to keep in mind and consider as we move forward with these. Again, our sort of source of truth for a lot of this will come from payer contracts. So once those are finalized that number will be incorporated into our next scale report and we'll have better estimates at that time. Michelle, you can go to the next slide. Thank you. One big piece here that we wanted to touch on as we continue to see advertisements for MA plans operating in Vermont. And as the board has spoken about in the past and I know was brought up during one carers budget hearing is sort of, you know, we're seeing these advertisements for MA and the growing population that's selecting those MA plans. So as you can see from this table since the signing of the agreement Medicare Advantage enrollment has more than doubled. Concerns here include really the biggest concern is the potential for higher average expenditures. So beneficiaries opting into Medicare Advantage plans tend to show lower average expenditures, which means the average expenditure for the traditional Medicare population may increase because they're losing those folks who would have a lower expenditure and sort of net that out. Similarly, since Medicare Advantage is categorized with commercial populations according to the terms of the agreement, it will potentially inflate expenditures within that commercial group. So we just wanted to sort of frame that, put that out there. There is a staff recommendation that will bring to you in a few slides, but I wanted to sort of frame that the best way that I could to show you how that population continues to grow. And again, we did include some breakdown of this in our 2020 scale report where we sort of offered a few alternatives where this population was removed from that scale denominator. We still did not meet scale, though we were closer. So I think just continuing to monitor this shift is really important. And I wanted to bring that to the board's attention. Michelle, you can go to the next slide, please. Thank you. So some key takeaways from this section. So again, the waiver of enforcement from CMMI, so we are no longer accountable for the targets that are in the agreement, though we will continue to report on scale. That is still a requirement. We will continue that through 2022. If the agreement is extended, which you heard at last week's board meeting, then that would continue through 2023, which means reporting would be complete in 2024. So just reminding you all of kind of the timing of that. And a couple of points that we just really wanted to make sure were reinforced here that scale achievement is not necessarily a reflection of ACO performance. It includes manufacturers like care patterns, insurance market patterns, movement to the self-insured market. We have to consider folks who might not report into vCures and so we might not have that information as well. Continued growth again in that Medicare Advantage enrollment space that could potentially impact our ability to increase scale and could decrease programmatic alignment with the Medicare in the Medicare space if those plans don't participate in the model. Thanks. So for scale recommendations, the big one here is that we're recommending, staff are recommending that OneCare work with MA plans operating in Vermont with a special focus on those plans offered by Blue Cross and the UVM MVP program. There are already existing contractual agreements with those two payers to develop scale target qualifying programs for the next fiscal year. So fiscal year 2023. Again, sort of just exploring this space, a consideration that we wanna make sure is included in the reporting manual and something that staff will also continue to monitor is the impact of changes in that MA enrollment and the potential impact on risk scores and how that could potentially affect OneCare's total cost of care targets. And I'll talk in a little bit more detail about that when we get into the Mathematica analysis, but I wanted to flag that as well, that risk scores here are gonna potentially play a part. Thanks, Michelle. So I will continue, we're on a ride now. I will continue to talk about the 2020 pay results. So again, we talked about this on November 22nd. All the payers came in front of the board as a payer panel, just a reminder here. Sarah also already talked through this slide. So just a reminder here of the settlement dollars that were realized for the 2020 payer program. Michelle, you can go to the next slide. Thank you. And a reminder of how that shook out in terms of quality performance. So a big thing here. So the quality scores, in most cases, as you can see, were reporting only and that's due to the public health emergency. So for those, the ACO was reported with awarded 100% scores for reporting on quality metrics. We are still figuring out what that will look like for the 2021 space. I think it will differ by payer program, but something to just consider is that given that the public health emergency is by no means over, we have to kind of think about how that has the potential to impact 2021 as well. So you can go to the next slide. All right. And now I'm going to move into a somewhat different topic. So as Sarah mentioned earlier, Mathematica Policy Research is the GMCB's analytics contractor for the All-Payer ACO model. Many of you are familiar. We've had Shulia Garovich present at board meetings before some on behalf of... for reports that they've helped us write for the model, but also she's come before the board just for her vast knowledge of many other things. So this specific analysis that we had done is comparing ACO and non-ACO populations from 2017 to 2019. Again, this utilizes a lot of claims data. So that's why the reason for that timeframe. Used a difference in difference and a regression analysis for a subset of measures. Those measures relate to cost. There's a couple of HEDIS measures in there. So similar to the HEDIS measures that we find in the All-Payer model agreement. And then there are a handful of prevention quality indicators measures. So in case folks aren't familiar with, I wanted to give a high level overview of the prevention quality indicators or PQI measures. They identify issues of access to outpatient care, including appropriate follow-up care after hospital discharge. And more specifically, they're population-based indicators that capture all cases of potentially preventable complications that could occur in a given population either during a hospitalization or in a subsequent hospitalization. So they're a really key tool that can often be utilized in community health needs assessments. So I think something to flag maybe as we think about CHNA, it's in our hospital budget process, but that is for another time. The report itself is very detailed. And I'm not gonna go through every measure that Mathematica reported out to us on. The report is linked on our website. And I think it's important to note that what we will go through are the measures that are closely aligned with one care's value-based incentive fund measures and or also really closely aligned with the all-pair model itself. What, that's fine, that's good. You can stay on the slide. One thing to sort of note is that what I will go through is the more closely related to the regression analysis findings. So that controls for things like member risk, age, gender, length of ACO enrollment and hospital service area. And again, the report itself has 16 measures. I will not go through all 16 measures. A couple of important things to note here, the results themselves are not causal. Since ACO participation depends on provider participation and characteristics of the patients, the populations of those attributed and those not are likely to be different. The non ACO group is less representative. And the reason for that is that patients who are not attributed are relatively more likely to be excluded due to an enrollment factor or $0 in expenditures, which can may distort the comparisons that we look at. And the Medicare Advantage population is grouped with commercial pairs. Again, that's per the agreement. That's how we look at them in that space. And that's how they were continued to be evaluated here. You can go to the next slide, Michelle. Thank you. So this is just showing the average membership that was included in that analysis again, 2017 to 2019. So if you look there of all of the membership there, those included in the analysis is about 85.4%. There's a reference slide later on that goes through each pair and those estimated or the membership included in the analysis. This one's just prettier. So we included it here, but there is a table for reference where you can look at the actual member month. You can go to the next slide, Michelle. Thank you. Pointing back to an earlier conversation and the recommendation that I gave on the Medicare Advantage, but specifically talking here about risk scores. So this slide really illustrates that difference and widening gap of the risk score, specifically here in the Medicaid space for the ACO and non-ACO population. So you can see in the commercial and the Medicare, I'm sorry, in the Medicare space, and the spoke Medicare, not Medicaid. You can see in the commercial and Medicaid space, those are relatively close, but in that Medicare space, you see that widening gap there of the non-ACO and the ACO attributed or the comparison groups there really widening. And also high above the risk score of the rest of the population included. Michelle, you can go to the next slide. Thank you. So here's a snapshot of some of the analysis. So again, this is just a subset of the measures that were included, but as you can see here, where we're seeing better performance in the ACO attributed group are those areas that are green. Blue is results that are statistically better in the group who are not attributed to the ACO, and then the orange is if they were not statistically significantly different. So here, one to point out is that follow-up after discharge from the ED for alcohol or other drug abuse or dependence, that is an all-pair model measure. And just looking across the pairs there again, 2017 to 2019. So just reminding ourselves that this would be only the first two years that the model was in effect. A couple of things I wanted to note just while we're looking at this slide or while folks are taking it in is from the ACO budget itself, part of that submission included the top prevalent conditions in their HSAs participating. And so one of the things I just wanted to call out was that anxiety was a top prevalent condition for many HSAs in the Medicaid program. And in those where it wasn't the top condition, it was the second or third most prevalent. And other prevalent conditions in that Medicaid space included depression and adjustment disorder or tobacco. And I called that out because some of those will fall under the mental health bucket in terms of the way things are coded or classified through CCM. ICD-9, 10. You can go to the next slide, Michelle. Thank you. So again, here same scoring color rubric. Again, so here we're seeing commercial ACO members have greater reductions in admissions for you're seeing here diabetes with long-term complications and that chronic obstructive pulmonary disease and the diabetes admission rate. So again, these are tied back to the ACOs, VBIF areas and also tied back to the all-pair model which is why I want to call them out. Medicaid members here, you're seeing hypertension and diabetes admission here and then in the Medicare results, we're seeing statistically better in the non-ACO group. But again, thinking back to the fact that risk scores are accounted for here and it's only the first couple of years of the model that we would be looking at. I think if we continue to assess this, our hope would be that we would see that change. And again, from the one care budget, hypertension was the top prevalent condition for all HSAs in the Medicare space and in the commercial space, the ACO identified hypertension and anxiety as the top two prevalent conditions in all of their commercial payer contracts. I'm sure I can go to the next slide. Thank you. Okay, this is my last one, I think. So some key takeaways here. One care's clinical focus areas or those VBIF priorities remain to the same. And based on the analyses that I just very briefly high level walked through, I really do encourage folks to look at that report on our website. The evaluation conducted, it really seems to be in line with the areas that one care itself has noted for improvement. And again, in the space where the state is committed to improving as a health of the population through the model itself. And with that, I believe I turn it over to Marisa. Thank you so much, Michelle. And thank you to everyone for bearing with us. We recognize that we are presenting a lot of material today. We hope even though there's a lot and we still feel like we've been flying through it. So we hope people will have some time outside of this presentation to spend some more time with the slides and the data we're presenting. But we are nearing the final sections, but we still have some information to go. So I am going to move on here to section. We're calling Green Mountain Care Board regulatory levers to foster a high performing health system. We're gonna start to try to bring it together here. So ACO oversight is an opportunity for the Green Mountain Care Board to drive results on all pair model agreement targets and more generally toward a high performing health system for Vermonters. We have been working with AHS and partners through the implementation improvement plan to drive improvement on all pair model targets. As well in May of 2021, we had Michael Baylett from Baylett Health present to the board on core competencies of high performing ACOs to help us improve our ACO oversight process. We have since expanded on this work in FY22 budget and certification review. You can go ahead to the next slide please. So to that end in the fall of 2021, the Green Mountain Care Board engaged the more health advisors to support its ACO oversight through a subcontract with Baylett Health. This was to provide expert consultation to support assessing one care's performance on two core competencies as identified by Baylett. Those are population health management and managing with data. And I'm gonna bring it back to Sarah's sort of high level recommendations at the beginning of the presentation that these recommendations that do have developed for us are helping us to ensure that the ACO management drives continuous improvement consistent with high performing ACOs. And we're hoping that these high level recommendations will help reduce administrative burden in the regulatory process with less focus on granular budget line item. So to introduce Joe for you, he has 30 plus years focused on building and developing regional integrated health systems, including integrating comprehensive delivery systems and health plans and building several provider sponsored health plans is a former vice president of strategy, innovation and population health at premier consulting solutions responsible for assisting physician groups, hospitals and health systems, health plans and integrated health systems and implementing population health management arrangements including ACOs with a team of 80 consultants and he was a health system CEO and leader for nearly two decades. It has been a pleasure working with Joe and with that I'm gonna turn it over to him to present his recommendation. Thank you, Marissa. Can everyone hear me okay? Can you hear me okay? Yes and see me. Thank you. It's a real honor for me to participate in such an innovative approach to healthcare. Healthcare is complex. One of my mentors Peter Drucker used to say that healthcare management is the most complex management because we have multiple constituencies we have multiple roles. And so my goal, if we can go on to the next slide here my goal today is to take just 10 or 15 minutes and provide you with a summary of the preliminary report that I've put together for the Green Mountain care board and for OneCare to really help move this ACO to its full potential. I believe you have such a unique and tremendous opportunity here to really do something that's outstanding and could be a national example for the country. And my goal is to really help identify some opportunities that you can implement fairly easily without a tremendous of expenses to help live to that future. So the goals that I've kind of tried to summarize are number one, let's make it data-driven. Data-driven benchmarking and dashboards will really help everybody. They'll help OneCare's management move towards more of a data-driven approach to management. It will help the Green Mountain care board move more towards a data-driven regulatory process. And thirdly, it'll help move the whole transformation of healthcare to more of a value-based model for patients and the population, which is the whole reason we all are here today to help people to improve care, to improve outcomes, to lower costs. And I believe what you're gonna hear in a few minutes now will help us do that. And I've tried to identify five key areas of recommendations. The first is this data-driven approach to benchmarking and dashboards. The second is integrating this into the OneCare Continuous Performance Improvement Program that they've espoused. And what I'm talking about is not just trying to match the averages or the mean of other ACOs, but to match best practices. This is really important because if you wanna be a leader, if you wanna be outstanding, you can't be average. You've gotta go to best practices and borrow from the organizations that have already implemented key pieces of best practices based on data, not based on reputation or rumor, but based on hard data. The third is recommending that OneCare be required every quarter to report benchmarking tables to the Green Mountain Care Board. And that this requirement would include not only providing the results compared to targets, but identifying where the best opportunities are for improvement based, again, on best practices, not based on being average. Fourth, developing a risk mitigation program which basically says each year, identify the highest risk areas to our organization, to OneCare, and developing a mitigation plan to prevent those high-risk areas from occurring. And I'll give a couple of examples in a few minutes. And lastly, using as a starting point the core competencies that Michael Baylett presented in May, and then adding on my experience of working at about 200 ACOs across the country the last 11 years, based upon those two experiences, I've identified 30 recommendations that are very specific for OneCare to improve their core capabilities and their processes in order to reach this model of being one of the most outstanding ACOs in the country. And again, these 30 recommendations are built upon these core capabilities. If we can go to the next slide, I would, what I tried to do is identify and break this down into component parts. The first part is to develop these dashboards and benchmarking program based upon each of the three major players, Medicare, Medicaid, and your commercial payers because you really have three ACO arrangements. Now, and start with Medicare because the Medicare data is available, it's reliable, we have over 10, about 10 years of experience in working with benchmarking in Medicare and it's your largest revenue size that you're dealing with. And then soon to be followed with Medicaid and commercial payer benchmarking, which again are based upon unique populations. All three populations have different attributes. Second, break those benchmarking tables into five areas and I've identified those five areas below the first being looking at use rates like ED visits per thousand. And again, it's a tool that many ACOs have already begun to measure and do a great job of moving patients out of the emergency room into urgent care, into primary care offices where they get more timely care, less costly care and really better care. The overwhelming visits to emergency rooms in America are non-emergent and do not need to be in the emergency room. The second area is measuring costs per capita and again, looking at what does it totally cost us to care for a person? What does it cost to provide primary care to a person? Specialty care, post-acute care, what are the levers we can use to lower overall cost of care? Third quality, for example, an excellent example of quality is diabetes. We know the old fee-for-service model rewarded complications with diabetics, the wrong thing to do. The new model, value-based care, rewards keeping the hemoglobin A1C below seven, it rewards keeping people healthy, it rewards keeping people with diabetes out of the emergency room, out of the hospital and lowering overall costs. We know that's better quality, lower costs. Third, patient engagement and satisfaction. We know that getting people involved in their care lowers cost and improves outcomes and there are techniques we can use that I'll describe in a minute to do that. And lastly, this is kind of a new area, it seems for a lot of folks and that's clinical appropriateness and that's using evidence-based clinical proven concepts to improve care and to make sure care is delivered in the lowest cost location at the highest quality and most appropriate location. And you can, let me give you a couple of examples because many people are not familiar with this. First is if you look at the CMS Care Compare website, there are plenty of examples on that website about how to lower utilization rates in inappropriate areas. An example would be using for back pain, using an MRI before other treatment modes are tried. We all know the majority of back pains are muscle pools, not necessarily spinal injuries and so many places are still doing MRIs before they even look at the muscle issue. There are others, the use of clinical protocols for sepsis, the use of clinical protocols for CT scanning. There's a national organization called Choosing Wisely and you can go on their website, ChoosingWisely.org and you can identify hundreds of clinical appropriateness criteria developed by over 50 physician professional societies where physicians have gotten together and said, let's figure out the best way to treat specific conditions. An example would be a child with a head injury, a child under the age of 10 with a head injury. We know that a child with a developing brain is susceptible to radiation exposure that could be damaging. In getting an immediate CT scan on a patient, a young child with a head injury puts the patient at risk for tremendous radiation exposure. The average CT scan has the same exposure of about 100 chest X-rays, tremendous radiation, versus observing the child for a 24 hour period. One ACO in Chicago that I've worked with adopted this Choosing Wisely criteria for head injuries in children and what they implemented was a program where the emergency department physician had to explain to the parents the two options, CT scan or observation for 24 hours. After a one year, 100% of the patients chose observation, the parents. And so what it did, it lowered the cost of care. They didn't have any bad outcomes. They didn't get sued because the parents were involved in the decision. This same principle has been applied by some commercial organizations to integrate this same protocol that I've just described into the electronic health record so that when the physician sees this patient with a head injury, a child, it immediately flashes into the electronic record. Have you asked the parents? Have you done a complete physical? Have you identified any neurological deficiencies? So this protocol really helps lower the cost of care but improves the outcomes also. If we can go to the next slide please. This area relates to continuous improvement. Taking this data and integrating it into a continuous improvement program that should exist at one care, which does exist. And it's again, applying these best practices like areas like post-acute care, care to patients, emergency department visits per thousand and then measuring the return on investment if we make these changes. I feel very assured that the return on investment if one care adopted these principles would be tremendous in the millions of dollars. Third, to have the ability to drill down to look at specific physicians, groups, HSAs, regions so that you can identify how we're doing in different parts of the state and how different practices are doing in adopting these principles. And then lastly, integrate these concepts into the dynamic planning process that should be in place for the organization. If we can go to the next slide. I mentioned earlier that quarterly reporting would be a key requirement. That again, to make this data-driven, that each quarter one care would report how they're doing against targets in these five key areas that I mentioned earlier for benchmarking. Now this comes with some cost. I recognize this. The cost to buy one of these systems is about less than $90,000 per year. Sounds like a lot of money, but when you're spending over a billion dollars for care and some of it is not very efficiently delivered, you can save a tremendous return on investment and I believe you'll get at least an eight to one return on investment if the board of one care, if the leadership of one care and if the providers in one care all commit to these concepts of adopting best practices. Again, it's not ethereal. It's pragmatic. It's where have places implemented these actions and it really does work. It's got a 10-year history of adopting best practices and identifying top performers. Where are those places that are doing this? What are they doing differently and adopting these same principles? They're not actions that are going to hurt people or they're not organizationally going to hurt one care. And then one care has got to track these. What kind of return on investment are we getting from this less than $90,000 investment? Again, I'm willing to believe that it's significant, likely in the millions of dollars. And then utilize these savings. Utilize the savings that are gonna occur to lower the rate of increase in costs and to use the savings to reinvest in other areas within the organization. If we can go to the next slide. The fourth area is risk mitigation and identification. And identification, as I've mentioned, identify the top three to five risk areas. This year, for example, two that come to mind throughout the country with ACOs. One is this spike that's occurring in COVID. What impact is that gonna have on 2022? The winter spike this year. And then second, we're seeing healthcare providers leave the healthcare field at record rates right now. Nursing turnovers as high as I've ever seen it. We're seeing physicians retiring. And the reasons vary, but many of them are frustrated with the volume of COVID patients, especially those who are not vaccinated. And these are healthcare providers who are committed to caring for people. And so they feel frustrated. So we're seeing a dramatic drop in the number of healthcare professionals. And so we've gotta come up with alternatives to address this, there are ways to do it. Team-based nursing is a great example of contingency planning for organizations. If we can go to the last slide, I appreciate it. And the last slide deals with these 30 recommendations in five categories that I've developed for OneCare. And these are very specific recommendations. I'm gonna highlight just a few quickly because I know we're about at the end of my time, but I did wanna share a couple with you. The first is in the governance and management area. And that is taking this data and integrating it into the strategic planning process, including using it as a part of the program evaluation process each year. Programs ought to be evaluated using data. Again, using the data from the benchmarking program, integrating it and prioritizing the opportunities within the strategic plan. Second would be board composition. A second recommendation is take a look at the board composition of the most successful ACOs in the country and you'll find certain attributes. One is it's competency-based board members. That means identifying the skills you need on a board like a nurse, somebody with nursing knowledge, somebody with IT knowledge, somebody with payer knowledge and recruiting those kinds of people onto the board that meet those competencies. Second is the most successful ACOs are primary care driven and the majority of physicians on boards of successful ACOs or primary care physicians. Third, ensure that the mix of the board members look like the people we're caring for. And that means gender mix, racial mix and those are three areas of governance I would urge one care to take a look at. The second area is provider engagement and network management. Their recommendation would be to develop a multi-year, say a three-year plan to move towards more value-based payment to providers that align value-based care with value-based payments. So the economic incentive is aligned with the care incentive like the diabetes example I provided earlier. The third area is patient engagement. What are the techniques that are used to get people more involved in their care? Simple things like open access scheduling is a great example where you can schedule your own appointments across the internet is just one example. The fourth area is population health management and there I've described in detail clinical appropriateness tools that can be used. Some of them are free, publicly available. Some you could buy later on, but just crawl, walk, run when it comes to clinical appropriateness. Start with those that are in the CMS care compare program. And then lastly, data management. Using data to really improve integrating data into the processes that are utilized. And then also developing an annual population health information technology plan that helps you move and prioritize where the data should be gathered, what your priority should be and then set up a priority setting mechanism for population health information technology. So I'm gonna summarize today. And again, this full preliminary report is posted on the website. So you can read it in detail and I hope you will. This is a great opportunity for OneCare in my opinion to be a national leader as an ACO. They have so many things that are aligned right now, being in a unique position that they are. I hope they'll take advantage of these opportunities and move to this data-driven approach to managing and to leading. And I hope they'll take a data-driven approach to transitioning healthcare in this country. It's an exciting opportunity. Change is not easy. Even the author, Machiavelli, he said, even the people who will benefit by change will resist change because people use all kinds of reasons and rationale. We want local control, you know? Does local control supersede using evidence-based care models? That's a question that needs to be addressed because sometimes people are doing things at the local level that aren't consistent with evidence-based care. And I think we owe it to the people we care for to deliver evidence-based care. So to conclude today, I think, again, you've got a great opportunity. I'm honored to participate and I hope that I can help move the needle a little bit further towards being one of the best ACOs in the country. Thank you very much. I appreciate it, Marissa. Thank you so much, Joe. Thank you so much, Joe. Let's see, we might need to turn off our... Someone needs to turn off their microphone. Getting an echo. So just a note, as Joe said, his memo is posted on the ACO oversight page. We can also put a link to that in the board meeting materials, but it's not currently with the board meeting materials. So we can get it in both places to ensure that people can see it and read. I'm gonna bring this together by presenting to you the recommendations that the staff have developed based on Joe's recommendations. So we took a look at Joe's recommendations, which are divided into those two categories, which are regulatory levers. And then he developed a set of recommendations that the ACO could use or reference also that the board could use to evaluate the ACO. But we have developed two regulatory levers, or sorry, regulatory recommendations based on his analysis and his work. So the first one, and these are new, so I'm going to read them out. They replace or enhance our former reporting requirements. So the first is that OneCare Vermont is to purchase and implement a reputable ACO benchmarking system for each payer program starting with Medicare. The selected Medicare benchmarking system should provide a payer-specific data set of peer organizations, ACOs, or integrated health systems against which to assess OneCare's performance, include identification of high-performing peer organizations and identify best practices of high-performing organizations. OneCare to select Medicare benchmarking system by February 15th, 2022. The benchmarking system must be approved by the GMCB staff prior to purchase and purchased by March 31st. These are dates that can be discussed. We're trying to figure out what operationally can actually work. This is probably the soonest that it could possibly be done based on our understanding of how the contractors work, but there's multiple issues at play. So don't read too much into the dates at this point. The Green Mountain Care Board expects to expand this requirement to Medicaid and commercial payer populations in FY23 and in spring 2022, budget update or revised budget OneCare should propose options for benchmarking systems for use in Medicaid and commercial payer programs in FY23. And the reason for starting with Medicare that I don't think we explained is that the benchmarking and data is most highly developed for Medicare. So we wanna set this up in a pilot sort of way or reporting only sort of way at first to test it. And then we have to dig a little deeper to get to the commercial and Medicaid, the proper benchmarking systems for commercial and Medicaid. Obviously we can talk more about that as we discussed its recommendation. You can go to the next slide, please Michelle. And the second one, second part of the recommendation is that the Green Mountain Care Board will issue updated reporting requirements in the ACL reporting manual pursuant to Green Mountain Care Board Rule 5.501 to implement a data-driven monitoring approach relying on payer specific national ACL benchmarking system or data sets. OneCare Vermont will report on performance and benchmarking results at least quarterly. OneCare Vermont will work with GMCD staff to finalize reporting templates by potentially June 30th with first quarterly reports. Quarter 1, 2022 due in July. And then the second part is that the FY23 ACL budget review guidance for OneCare Vermont should reflect this change in approach and introduce performance targets linked to national benchmarks along with enforcement mechanisms where OneCare Vermont does not perform at the levels outlined in the guidance. So the rule does allow the board to set benchmarks as part of our review. And this would give us the ability to do that for performance. I also want to note here that the intention is for this type of quarterly reporting to replace a lot of the sort of more ad hoc reports that we currently issue and give it a sort of more standardized high-level look. So it is intended to replace and not add to the burden of reporting that we currently have. You can go to the next and final slide please, which is just a reminder of the timeline of what's next. We have discussion period and we will come back before you as needed and for a vote. Thank you all for your time. That concludes our staff remarks. I'll turn it over to you, Mr. Chair. Thank you, Marissa. I'm going to start the board questioning with Board Member Lange-Robin. Hi, thank you. Thank you all to Joe and all of our staff. That was very thorough and comprehensive presentation. There's a lot to Q1 and to digest. I would not say that I have specific questions, but I do have some comments I wanted to throw out in terms of what I'm thinking about in terms of the recommendations for other board members to reflect on if they would like and also just for the staff to think about for next week. And I'm going to start from the most I'm going to go backwards because of my my notes. So I like the idea of moving to a more data driven approach. I think that's something that we have been trying to do in this process as it has evolved. So I'm very interested in the recommendation related to the benchmarking systems. I think that will also be very helpful in terms of moving us towards a system at the provider level that is data driven. And if there are systems out there that we can piggyback on that seems more efficient than trying to build our own, which is sort of what I think we've been trying to do. So I'm in favor of that approach and that requirement. In terms of the Medicare Advantage plans, I like the idea that one care would focus in 2022 on developing scale target programs with our local Medicare Advantage plans. I know that's been a real shift for us to see more activity in this area. So it's kind of a mixed bag. But I will say one of the pros of having a couple of local Medicare Advantage plans in terms of health care reform is that I think we may have more opportunities to work directly with those plans than with some of the national players like, for example, United or some of the other national Medicare Advantage plans that have dominated that Medicare Advantage marketplace in Vermont prior to the Blue Cross and MVP plans entering the market. So I do think this is the time is now to get ahead of that so that we can start to think about how that fits into health care reform overall. On the population health management programs, I think that as the overall one care budget for the organization or the GAP budget, as Patrick referred to it in the slides, shrinks, I think it does bring into it creates a little bit of a worry about so how do we continue to fund the population health investments as we move forward in reform. I did I generally it's disappointing I think to see those numbers go down and it's disappointing to see a movement away from primary to more community prevention efforts. On the other hand given the Mathematica analysis and what we're seeing in the quality areas and the clinical issues, I think taking a step back and really doubling down on those clinical priorities makes sense and to a point that I think just is made in prior years, we haven't really seen whether or not something like the Innovation Fund for example will actually is actually doing its job of creating best practices in state that then can be spread. So most of the reductions in that area are focused on areas I think outside of that core clinical prevention. So at least I think it the proposal that one cares brought forward is consistent with their overall focus to try and take a step back and really focus on the the clinical areas that need focus on for quality. And then I think I will end with the VBIF. So I think one of the areas that have come come up in the prior presentations around the one care budget is both the fiscal year 20 settlement as well as some of these shifts in population health investments. And I think Tom will appreciate my thinking about the settlement dollars which is these are one time dollars. And so I think under the one care policy there's a couple of options where they can distribute those back to the providers which is the deal that the providers made or reinvest them in the VBIF or other population health investments. The fact that these are one time dollars that in my mind at least seem linked to some of the strange care patterns that happened during the pandemic I would like to see some of those dollars reinvested in the VBIF and particularly for the VBIF because it is a program where there can be carry forward from year to year. And so you're not using one time dollars to invest in a program that is ongoing in which you would then need to cut the following year when you don't have this unusual shared saving situation based on strange pandemic related care patterns. So I'm interested to hear where the staff will land on the VBIF concept. I think that's a good place to focus investment and it also I think is a good place given some of the results that we've been seeing in the quality area and the Mathematica analysis. So that's kind of where I am. Overall there weren't any conditions that I was not in favor of. I think the staff did a good job of coming up with both our standard conditions that we typically have as well as thinking through kind of key areas of concern this year. Thank you Robin. Next I'm going to go to board member Pelham. Tom. One time money the bane of my existence. I want to thank the staff for an incredibly thorough presentation here. There's so much detail that you know my head is spinning and I know that I will never absorb it all. But since you're there and you have all your expertise in certain areas I feel fully fully protected from my ignorance. The I guess I'd like to start with one question that I have like one statement and a couple of short questions. The one question I had written down here before the session was in the two thousand twenty two budget data submitted. Can we see the commercial payments are scheduled at two point nine percent in FFP as contract revenue and Marissa answered that question before I got the answer. And she said no basically that you can't find it. And to me that is incredibly disappointing that that we have our largest payer out there. The commercial payer is by any any standard the largest one in Vermont in the hospital budget process of over three billion dollars in total revenues commercial payers are one point six billion of that are fifty four percent. And payment reform is one of the three core capabilities that one care has in their strategic plan. They say in their narrative that payment reform is the pivotal first step in managing overall growth in health care. And so here we are in a situation where we're trying to get married to the commercial folks and they don't seem to want to do it. We go through the hospital budget process and we find that in terms of the of NPR hospitals only comprise three tenths of one percent of hospital revenue. We saw in the chart I think it was slide sixty five that of the imbalance in terms of the public payers versus the commercial where the the public players Medicare, Medicare and the fifty one fifty four percent of their payments in in FPP and I agree some of that's the kind of loosely structured FPP but it's still FPP and the commercial of a carrier one percent. And so there's a part of me that says judge them by their actions. Maybe they don't want to participate. You know, I don't know that but I do think that that we need to come to a clear understanding with the commercial carriers, whether or not they want to you develop a working effective relationship or or decide whether or not the resources that one care is spending on on them are are being well spent. It just it just the they're they're too big a big a piece of the pie to have year after year after year not have developed a meaningful, substantive relationship with them. As we have with Medicaid, Medicaid is full FPP. They have a cost shift problem that I think we need to address. But they're they're in the end of payment reform and hopefully our efforts with Medicare, you know, over the next year, year and a half will will bear substantial fruit. And maybe that's where we should be focusing our energy on in the areas where where the relationship is is is collegial and and forward-looking. My two questions are the first one was did we get any answer back from one care about their participation in the benchmark plan review? Me, this just seems a one time opportunity, Robin, the benchmark plan, a one time opportunity to take a look at the benefits offered by Vermont's benchmark plan, which was crafted in 2013, predating all of this effort and make sure that is as as well aligned with our our goals for population health improvement and and not let this go by and even and even making sure that it's in line with our goals for popular health population health improvement before discussions, because it's going to come to us at the board at some point in time, we start talking about adding benefits to to to add to the burden of health care costs. Let's make sure that that plan is is very well structured relative relative relative to the population health. And I know maybe it's the only thing we'll find when we look at it or one care would find that it should do a brief a pre diabetes program, which we don't have in our benchmark plan. But my guess is that there is some more there. We'll probably find some high cost benefits with low cost, you know, high cost benefits of low value. So that to me is an opportunity and it's right before us now. It's not going to be here next year. And I think one care one care needs to take their talents and get engaged. And my final question had to do. With as I was at the beginning of the presentation with the the the cost of care trend developments. And I think it's a appendix four point three. It's the I would like just some explanation of these basic experience adjustments because those are they start with the twenty twenty one per member per month benchmarks. And then they insert these base experience adjustments. And I wouldn't mind if they weren't significant, but they end up substantially changing the base for the twenty for that for the twenty twenty two calculation for Medicaid traditional. It was a six point three percent increase and for Medicaid, the expanded Medicaid, it was a fourteen point seven percent increase. And so those are big numbers. And I'd just like to know kind of what what comprises a base experience adjustment. So that's it. Again, I want to applaud you all for for this. And and I agree with Robin and Robin in terms of for one time use of funds. Rarely do I get the chance to do that. So thank you. Thanks, Tom, I can take those questions. I think they're both on my sections. The first one regarding the benchmark plan, we have not received any additional information or response from one care on that beyond what they stated in at the hearing. Which I pulled up real quick that, you know, Tom Borey stated that they're happy to be a contributor in terms of learning what's more in the plan. He's looked into it a bit and has had some concerns around now that they're a 501 C3 organization being cautious around anything that looks like lobbying. And so it looks like they've there's been some thinking about it, but I don't have any more concrete response from them around their engagement with the benchmark plan. And on your second question on the trend rates, I'm going to have to punt that one to next week with Sarah Lindberg, who's going to talk about the trend developments in more detail. You know, one response. I know what Tom Bore said at the hearing. He's concerned about being a lobbyist as a nonprofit. But I bet you there's a lot of nonprofits that are engaged in this benchmark plan, including insurers, Blue Cross News Shields. So I don't unless some legal mind tells me I'm wrong, I don't accept that as an answer and and just really think that, you know, with all the data and analytics, which is one of one cares, you know, founding foundational efforts, they could be an important contributor to our benchmark plan. And they should be at the sheet. They should be at the table in my view. I don't I don't buy the nonprofit argument. Thank you, Tom. Any other comments or questions? If not, I'm going to move to to a board member Holmes, Jessica. Great. Thank you. And again, I want to echo the same huge gratitude to the staff and to Joe for all the hard work here. It's clear how much work was put into this analysis and, you know, really helpful key takeaways from each section and thoughtful recommendations. So there's a lot to digest. I have a couple of initial reactions and a couple of questions. You know, I think like some of the public comment, I'm concerned about the shrinking investment in population health programs. And again, it's not going to be a surprise. What appears to be few resources devoted to program evaluation and return on investment analysis in the in the budget. I think like the staff, I also worry about the weaker incentives in the network based risk model, coupled with smaller risk corridors, although I recognize that's a covid adjustment there and less funding for the value based incentive fund, which Robin and Tom already talked about and we heard from the staff as well. I guess essentially I'm not sure the carrots and the sticks are strong enough to incent the delivery reform that we want to see. So, you know, I understand also it's a work in progress. And, you know, some of the some of the suggestions made by Joe, I really appreciate nobody's going to be surprised to hear that I really appreciate recommendations around data driven decision making, the importance of program evaluation and the need to ensure that care delivery is appropriate and evidence based and really using some tools to analyze that. So I've thought a bit about this. I have more to think about as well, but I appreciate the approach the staff is taking. You know, a key takeaway from me is maybe we don't we aren't micromanaging line items in the budget, but we are better monitoring ACO performance and outcomes and doing, you know, a better job at holding the ACO accountable to best practices and national benchmarking standards. I think, you know, the ACO is more established now. It's more mature. And I think we need to start comparing, you know, one care Vermont to high performing ACOs across the country and requiring real accountability within the network. And so I fully endorse that condition requiring one care to purchase a Medicare benchmarking system for use in 2022 and to identify benchmarking systems for Medicaid and commercial by March of 2022 with use in 2023. I have a couple of suggestions on the recommendation on I think it's slide 41. Slide 41 is the recommendation around around the presentation on or before April 30th of 2022. One addition I would like to see to that slide is in that presentation. I'd like to hear about the proposed Medicaid and commercial benchmarks that they in the slide before it says they have to support and submit rather by the end of March. So I would like to see and hear about what those proposed benchmarks would be in their April presentation. In addition, in that April presentation, I'd like to see the ACO present a report on the results of the evaluations that they actually are doing as they described in their budget submission. One relates to care coordination and the other relates to variations in care. So if you go back to section seven of their ACO budget submission they outlined how they evaluate the care coordination model. They monitor process metrics in terms of establishment of care teams and care plans quality assurance monitoring caseloads and counter tracking and they do outcomes evaluation. ER utilization, hospital admissions, preventative care, length of stay, etc. So I would like to see the results of that evaluation presented in April. I would also like to see the results of their HSA level variations in care analysis presented in April. And in light of it's a revised budget presentation. I guess what I really want to hear is how their revised budget addresses the weaknesses that they identify in their evaluation of the care coordination model and how their revised budget addresses HSA specific variations in care that add unnecessary cost to the system and or compromise quality. I also recall at the hearing that they were pursuing a potential relationship with UVM, the academic institution, the university to explore additional evaluations. So I'd like to hear an update on that as well. So I want to make sure that in April we're hearing about the evaluations that they're doing and how their revised budgets actually incorporate the learnings from those evaluations. Like Robin, I'm also interested in the staff's recommendation around the value based incentive fund and potentially using one time money to increase that fund. Again, trying to increase those those in this case, carrots. One question I had around slide 48 was this was with respect to the benchmark trend rates in the payer contracts. I just wondered if we should include a date when those materials and conditions C2 would be due to the board. There was no date in there. There were some dates and other requirements. So I just was going to throw that out there. This is actually more a question for Joe. I really appreciated your slides. I think it was 109 and 110. You know, again, these recommendations around benchmarking and comparing one care to high performing ACOs. And I wanted to ask you how we should incorporate the information that we glean from these suggestions on the ACOs performance evaluations into our hospital budget process. And maybe this is a conversation for a later time, recognizing that we're in the interest of time here, but say that there's an HSA that seems to be underperforming on cost or quality or not applying best practices for clinical appropriateness. And this emerges in our ACO data driven performance evaluation. How should that be incorporated into our hospital budget process, if at all? So that's kind of a question that I would love to have the answer to, but maybe not at this moment in time. And then the second question around the next slide was slide, I think 112, one of the comments around provider engagement core capability. And I wondered how should one care Vermont measure meaningful provider engagement in my mind? And I think I mentioned this in the hearing. It's not enough to sign a contract. The question is if you're really engaged, are you reforming your delivery system? Are you shifting resources towards more primary prevention and the social determinants? Are the compensation contracts within that organization reflective of value, not volume? Those are the ways in which I would sort of want to measure true provider engagements. I wondered if you had suggestions for that. You want to take that, Joe? I think your first question, I think you're right, that it's going to take a more extensive discussion. And I've got some ideas, so maybe we can chat about it later on. The second question, I think your points are all very valid about measuring engagement. There are different tools we can use about patient engagement. And one of them is this basic satisfaction. There's some great CMS satisfaction measures. And the two that I find that are the most global, globally helpful. One, would you recommend this provider to other people? Yes or no? And then the second is on a scale of one to 10, how would you rate your provider? And those are two questions that I think a lot of ACOs are actually attaching incentive payments to. And that starts at the more global level. And then I think you can work down to the level of detail. But probably take a greater discussion. That's great. But actually what I was asking about was provider engagement. And I really mean true provider engagement in terms of work. We're seeing and witnessing at the provider level a change in delivery, a change in resource allocation, a change in compensation, contracting. So how does the ACO measure true provider engagement other than just participation? Yes or no? Yeah, I think number one is the fact that they really have a very high level of participation in contracting. Number one. And then number two, there are some tools you can use, some survey tools that would get to similar questions that you've identified. And so maybe talking with one care about helping them to craft a questionnaire for providers that would get to some of those questions might be a next step. Okay, that's great. Thank you. And I just have one more question for the staff, which was around. This is slide 114. Recommendations for the 2023 ACO budget guidance. And again, I think I'm going to kick this over to a future conversation, but I noticed in there there was a suggestion to incorporate both performance targets linked to national benchmarks and enforcement mechanism. So at some point in the future, I'd love to better understand what types of enforcement staff have in mind for not meeting national benchmarks. We have enforcement mechanisms in the hospital budget process, and I'm curious as to what enforcement mechanisms and thoughts the staff have on what that would look like in an ACO process. But again, in the interest of time, I'm just going to throw it out there or something to talk about at a later point. I can make a brief note about that. It's definitely longer, a bigger conversation, but that it would probably come in the form of some kind of performance improvement plans or corrective action plan or some mechanism like that. So right now we have all these ad hoc reports. Like I said, we're going to try to eliminate a lot of those in favor of this more high level reporting. But if we see underperformance in some areas, then we would require additional reporting, performance improvement plans or something like that. But we would have to sort of work that out through the pilot phase of this. Yeah, hugely helpful. Thank you. Thank you all. Thank you, Jess. I'll just touch on a few points. My colleagues have really hit most of them anyways. So I just want to say that one of the things that jumps out at me just as it did to Robin is the decrease in the population health investment. And that's an area of concern to me. I have some optimism in some of the recommendations. And I think everybody should have a goal that in a few years other ACOs in the country are benchmarking against one care of Vermont because one care of Vermont is leading the way. And so I think there's some true optimism in some of the recommendations. That doesn't mean that I'm not a little bit disappointed on some areas. And it was easy to believe very strongly that we should focus on those three key areas that were pointed out three, four years ago. But at some point I always believe that we would expand what that focus would be. And I think Joe brought up a number of potentials for best practices in a lot of different areas. And this isn't something that has to be invented. I mean, there are places like Intermountain Health and others that have protocols in place that could be copied relatively easy. And so for that reason I kind of believe strongly that Tom was really on a very important topic and that one care should be involved in the benchmark discussions, the benchmark plan. And we have to keep in mind that our goal isn't just to do things for the attributed population. It's to do certain things for the entire population of Vermont to create a healthcare system that's sustainable in the long term. And I do think that at some point in time we have to start moving to a much broader range of areas where there can be significant quality improvements and significant savings. On that same vein of thought, another concern of mine is the fact that we understood last year why the risk corridors were reduced. But if you're truly going to have providers that are invested in making the type of changes that are necessary, I think that risk corridor has to go back to where it was previously. I mean, it's just too small a risk corridor for I think somebody to take it totally serious. So that's a concern for me. Other than that, I think we've beat the other things to death. So I won't go there. But I do want to say that again, I do have optimism. That doesn't mean that I have some very big concerns. So with that, I'm going to ask before I go to the public for comment if the healthcare advocate has any comments. Thank you, Mr. Chair. I do. I should always be prepared to have a comment in case the chair just goes ahead and calls on me. Thank you. I will echo a very complete and detailed analysis. And I would offer a thank you back to your staff that my staff has been working in a good collaborative relationship. I think, well, just a few quick comments. I do work for a not-for-profit and do participate in the EHB workgroup. And but also to recognize that the EHB workgroup is considering services like hearing aids, whether adult dental could be offered in the EHB eyeglasses, et cetera. Not, that's a very different level of question than the concept of, well, just want to, that's the kind of questions that are being asked and evaluated. The other comment that I, well, the one other thing I think I'll say is just I want to admit that this is a pet peeve. I don't consume a tremendous amount of media, but when I do, I can't help but hear healthcare organization after healthcare organization advertising to me. And it's quite overwhelming, one after another, after another, entities that are regulated by you all. And since, and so I make this comment in the context of that, feeling a bit overwhelmed by it. The, I know that one care has been advised by you and by others to do a better job of telling its story. And I don't disagree with that, but one care, our care, better care, I don't think accomplishes that. And so I, and I don't know how much is being spent on, on such advertising and I don't know how it compares to public health investments or data analysis or other things that I think would be broadly supported or I would broadly support, but it is a pet peeve of mine to hear so much money being spent on name recognition. That's my comment for the moment, Mr. Chair. Thank you. You should be happy that yesterday was December 7th and we won't have to hear the Medicare Advantage ads all the time. Thank you, Mike. With that, I'm going to open it up for public comment. And if you could raise your hand through teams or if you're just on a phone, speak up and I'll recognize you. The first hand that I saw raised was Walter Carpenter. So, Walter. Wow, I'm first this time, Kevin. And the interests of Brevity, I'll try to keep this real short. I have about a thousand questions. First of all, I'm glad I'm not a board member to have to digest all of this. So, compliments to them who can do it. Second of all, I'm glad I'm not a staff member to have to put all of this together in the first place. One of the things that I noticed in that I am not a business major, not an economics major, and not a lawyer. I am a patient, activist, writer, and liberal arts man is that all of the words are most of them used in this like benchmarking, population health, data management. Exactly what do those mean? And one of the difficulties with one care on the street level is that nobody knows what all of these mean and what they're talking about, what they're trying to suggest. Like the Affordable Care Act, for instance, covered how the unaffordable care act was not affordable for most people because they always have these huge deductives. And so you see a lot of that going on. The second comment is kind of just a view from the drone of overlooking it from the drone view and seeing the whole thing is it makes me wonder, A, why Americans can take such a simple comp thing as providing health care and make it so vastly complex that a NASA engineer couldn't understand it. And how is it that an entity with a $1.36 billion budget is going to improve care and actually cut costs while improving care? And I share the concerns of Kevin Mullen that he just echoed about the population and so on. And I'll stop it there just to keep it short. Thank you, Walter. Is there other public comment? Julie Wasserman. Yes, thank you, Chairman Mullen. I have a couple comments. With regards to primary care, primary care accountability pool, wondering if someone could explain the rationale for having the struggling independent primary care physicians bear more risk than the hospital-based primary care practices that are in a much more secure situation. It looked from today's presentation that the independence are bearing 8% of total risk and the hospital-based primary care practices are bearing 7%. What slide number? Slide number 61. So which member of staff presented that slide? Mr. Chair, this is Sarah. I am happy to attempt a response at that. And now I'm also trying to find the slide. You know it's bad when you can't find your own slides because there are so many of them. Thank you very much for your question, Julie. So what we've tried to show here on the slide, and this comes from One Care's response to the round two questions, is that within the primary care accountability pool, the share of the risk paid into the pool is based on attribution. So we've included the proportion of the HSA attributed through each category. So for example, in Bennington, 31% of all Bennington attributies were attributed through non-hospital primary care, 69% were attributed through hospital-based primary care. And that is how it's broken out. So if you, you know, kind of do the math of the total primary care accountability pool amount for each HSA, you'll also have HSAs linked to the attribution numbers that One Care supplied in their round two questions response. Well, it's something that I think the Green Mountain Care Board should take a look at because we do know that our primary care physician workforce is not stable or thriving or growing or being strengthened by the ACO and to ask the independents who have borne a tremendous amount of challenges to bear more risk than the hospital base. Something about that just doesn't feel right. So that's my comment on primary care. And, you know, as Joe mentioned, this is the best ACOs, the strongest ACOs in the country are those with a robust primary care involvement. So my other comment, oh, I just want to, I do want to thank staff for making some distinction between reconciled and unreconciled payments. That's something that's a really important piece. Thank you for that. And also thank you for the 2021 scale numbers by payer program. That's also very helpful. So thank you. With regard to the ACOs quality performance, today's presentation made scant mention of the ACOs 2020 dismal performance. The ACOs performance with Medicare lives showed a worsening in half the measures. It was even worse with Medicaid nine out of 10 measures were declined from the prior year. Blue Cross Blue Shield sees no difference between ACO and non ACO lives. And as you did know, MVP scored 50 out of 100 points. So that's a pretty dismal picture. And I want to note it. And we, I think, have to take that into consideration. My specific question is, oh, where could we find Diva's final report on the 2020 results in years past? It comes out in October. And I have been unable to find it so far. Sarah, the Diva report is on our website. My understanding is that Diva does not yet have the report. But we will double check that with Diva. And if so, and if we find something different, we will get back to you. Thank you so much. Okay. Thank you. Next, I'm going to go to Dale Hackett. Interesting. You introduced the word Mathematica. The first handbook of mathematics I bought was Russian translated. And it was actually called the Handbook of Mathematica. And is now a rare book, in fact. I haven't seen that word since then. So I'm concerned about the population health and not doing more investment in that, because I also think of that as also coordination of care or that coordination of care is in that process. There's a lot I could speak to. But what I want to specifically ask is way back when they were talking about the Medicare Advantage plans. What was their take on that? I'd be really curious to know. I mean, they filled my mailbox almost three times with advertisements. I got so sick of it, I called them up and they did this quick analysis to see if I was eligible. And of course I wasn't. I knew I wasn't. And then they wouldn't talk about the plans. So that had me wondering just how much value is there to these plans? They certainly put a heck of a commercial blitz on them. Well, Dale, I think many of us share your concerns about the value of the Medicare Advantage plans, but I don't think that's really the topic of discussion today. Okay. In terms of how we're doing, I'm disappointed, but I'm not surprised. I expected that with COVID and the pandemic, we've got to go down before we can come back up. I expected it to sort of tear apart the system and really challenge it. So I think it's more important what we do going forward and learn from our mistakes and or whatever you want to call them. If there aren't mistakes and just there's better policy out there, such as fee-for-service doesn't necessarily work. That's been learned or maybe people still think it does. But there's a lot to learn in here, a lot to digest. And I hope the consumer doesn't get lost in it, that we stay focused on the value statements and what actually benefits the consumer. Of course, we want the hospitals to survive and stay vibrant as well, because a vibrant hospital can serve a consumer well in terms of those quality statements and values statements. That's the end of my comment. Thanks, Dale. An important point, because a vibrant hospital is part of a patient-centric model because the patients need that care available to them. And I just want to say that today, the numbers were the worst that we've seen since the start of the pandemic. We've got really the worst situation in the last two years as far as the availability of care, especially when it comes to intensive care, because what we have in the state of Vermont today is a lot of people needing care that's not COVID related, but still needs intensive care. And to think that we have over 30 beds being taken up in ICUs with 90% of the people in those ICUs for COVID reasons being not vaccinated, it just makes me wonder where the team effort is on making sure that everybody's doing everything that they can to not just protect themselves, because I've heard people say, what difference does it make if I'm vaccinated? It does make a difference, because if we're going to get this thing under control, we need everybody's participation. And when you do get sick, you're not just hurting yourself. You're denying actually a bed to someone that may need it for another reason. And for that, I would hope that all Vermonters would start being a little bit safer and start using masks whenever appropriate, especially when going out. And the only way that this is going to get beaten back is if we all work together. And we have been a leader for the nation. And we need to get back to being a leader for the nation if we're going to be successful. Is there any other public comment on the one care budget? If not, is there any old business to come before the Green Mountain Care Board? Is there any new business to come before the Green Mountain Care Board? Is there a motion to adjourn? So moved. Second. It's been moved and seconded to adjourn. All those in favor, please signify by saying aye. Aye. Any opposed? Thank you everyone. Be safe, be healthy. And for those who won't be at our next couple of meetings, have the most joyous of holiday seasons.