 My name is Kevin Mullinger of the board and I'm going to call this meeting to order. I'm going to start this meeting on a little bit of a sad note. As we recognize the passing of the former director of health care reform at the Green Mountain Care Board, Richard Slusky, and anybody who knew Richard knew that he had a zest for life. He wasn't afraid to share his opinions and that's why we respected him so greatly. I first met Richard when I was in the legislature and he testified on numerous occasions before the Health and Welfare Committee and although he rooted for the wrong teams, we had some great conversations and we're going to miss him and at that point I'll turn it over to Susan Barrick because Susan worked more closely with Richard than I did and Susan if you could say a few words. Sure, thank you so much Chair Mellon and you know I can't agree with you more Kevin in terms of how you described Richard. He was incredibly passionate and sometimes that passion would be hard to deal with as an executive director but he always had his mind in the right place and that was to help Vermonters with access to affordable, high quality health care and his work that he did here at the board for those years lives on in the work that we do every day and I just want to speak for myself and for the Green Mountain Care Board staff and the board that were terribly, terribly sad at his passing and our hearts are with his family right now and we pray and hope that they can get through this very difficult time but you know it's a hard time but we do have those memories from Richard and I can speak for myself I learned a tremendous amount from him and I'll turn it back to you Mr. Chair unless you would like me to do you want me to talk about I just have to brief public comment announcement if you want me to get into that. Yes, why don't you proceed with the executive director's report. Thank you so just the ongoing public comment period that we have had up since February of this year that we are taking any public comment regarding a potential next agreement with CMMI on an all-payer model and any of those comments are being shared with our colleagues at the Agency of Human Services and the Director of Healthcare Reform as well as the governor's office as they are leading those negotiations on a next model and just in terms of the scheduling we have a TBD for our meeting for next week on the 29th we will see how things go today but if we don't need to have a meeting next week we won't and then our schedule for January will be posted towards the end of next week so folks can see what we have planned next year and I will turn it back to you Mr. Chair thank you. Thank you Susan. Next on the agenda are the minutes of Wednesday December 15th do I have a motion? So moved. Second. It's been moved and seconded to approve the minutes of Wednesday December 15th without any additions deletions or corrections. Is there any discussion? Hearing none all those in favor of the motion please signify by saying aye. Aye. Aye. Any opposed please signify by saying nay. Also I just want to let the public know that we do have a new board member he will be starting on January 2nd his name is Tom Walsh he is a PhD he started his career in physical therapy and has immersed himself in academia both at Dartmouth and for Boise State in Idaho. He's a member of the Joint Commission here in Vermont and has a deep passion for health care reform and we look forward to working with him starting in January. So with that I'm going to move to the 2022 Medicare benchmark proposal and I'm going to turn it over to Sarah Lindbergh. Sarah. Okay my computer froze for just a minute. Are people able to hear me? We are. Okay. That was scary for a moment. And you can see my screen all right. Yes. Great. All right so we're here to finish up the recommendation for the benchmark and potentially vote on it. So we have a little bit of follow up from last week to start with. One is showing my work about the Medicare premium calculation and then giving you the exact headroom I'm anticipating for our performance to date for the Medicare program. And then we'll talk about the recommendation and vote if you're feeling it. So the total trend basically is weighted about half and half 51% is part B claims and 49% are the part A or inpatient hospital claims. And of that part B outpatient claims there's two different rates depending on if the member is eligible due to being age 65 or older or if they are eligible due to disability. So the rates and the rates of change were a little bit separate for that population. So of the 51% that is in part B, 86% of those expenditures are associated with people age 65 and older and 14% are associated with the disabled beneficiaries. But wait a minute 7.3 I thought you said 5.5 last week. So recent event is that Congress passed legislation to extend Medicare's exemption from sequestration. So sequestration is something that's happening federally across the board. It's not just a Medicare thing where they started deducting 2% off the top of federal expenditures. It started in the Obama administration in 2013 I believe. And so it was going to be reinstituted for calendar year 2022. But some last minute changes have postponed that. So the current legislation says that it would be reduced at it would be reinstated at a reduced rate in April at 1%. So April, May and June would have a 1% sequestration and then it would regress back to the 2% sequestration. I think because you know I think there's a lot to be seen about if and how this pans out I would recommend kind of taking that factor back out of the calculation and dealing with it at settlement because it's a lot easier to deal with it than then kind of assume it's going to happen. We know it won't be 2% the whole time though. But you know that is something important to keep in mind with all these growth rates is that that 2% was kind of you know fake growth that was just a removal that wasn't really about spending so much as a federal sequestration. So so if you do click through here is the Part B announcement from the federal registers. Gosh, I can't remember what it's called. Something about examination exhibits. But you can see we take the costs. We back out the cost sharing from the individuals who are actually beneficiary. So those deductibles and insurance aren't on the table for the ACO. They are only at risk for what Medicare pays. So if we look at those benefits but add back the sequestration, that's how you'll get back to my math. You'll notice in red there I've circled the contingency margin, which I did not include. Again, that has to do with the uncertainty associated with additional COVID expenditures, which at this point are omitted from the ACO's risk and also the Alzheimer's drug that's very expensive that may or may not actually be approved by Medicare. So if it is not, you know, even if it were approved and that's a big if, we would make sure that the ACO was not at risk for that completely new benefit. So it seemed appropriate to exclude that from the calculation. So that's how I came up with my numbers. So that is why instead of a 5.5% trend rate, I'm recommending a 7.3 trend rate. It's the same principle, just adjusting for that sequestration amount. So the Green Mountain Care Board decision really is choosing something in my judgment no lower than 3.5% up to the maximum trend, which is 10.4%. I show with the current experience estimates what that would sugar out to. So if with a 3.5% trend, the total amount of risk presented to the ACO with a 2% corridor is 10.9 million. That creeps up to 11.6 million with a max trend. However, we know that we're going to lose additional beneficiaries over the course of the year due to the attrition. So if we assume that is the same in 2022 as it was for the benchmark population in 2021, that would go down to 9.9 million to 10.5 million of risk up or down for the ACO with a 2% corridor. I think it probably will end up being a little bit lower than that, but time will tell. So I guess the take home point here is that with that 2% corridor, the trend rate doesn't do much for the bottom line. So in terms of where we're standing for performance, so on the left hand part of the screen, you'll see our annual growth. That is not what we're actually on the hook for according to the agreement, but we always check to see if we're on track. So we're looking for 3.5 to 4.3% annual growth. We're going to blow that out of the water in 2021, understandably. We would blew it under the water in 2020, unfortunately. So the annual target was 4.2%. Our estimates are coming in from the 9% to 15% range. Again, a lot of uncertainty about what has left for us in 2021 here. And that's true for both populations, the ESRD population. The target was 2.3%. Again, the growth there is a little less dramatic just because their needs tend to be more stable and less sensitive to elective type procedures. Obviously a lot of that preventative care is taking its toll, but they need the care come what may. So our growth rates are set for 2022, 10.4% for the non-ESRD population and 7.6% for the ESRD. But again, what we are on the hook for is the growth to date. So our compounding growth to date using this range of estimated annual growth would be between about half a percentage point below zero, up to almost a percentage point above zero for the non-ESRD population, which is well below the growth target of 3.9%. We have up to 5.2% over the life of the agreement so far, assuming not factoring in any extensions for the non-ESRD population. And then below that, the ESRD population is varying from negative 2.4% to 0.1%, which is well below the 2.9%, and we would have to grow up to that 3.9%. That is where we stand, a lot of confusing things, but I think the message is we've got plenty of room to grow. If Medicare were to grow by 20% in 2022, we would still meet these targets. However, we would likely not meet the all-payer total cost of care targets. So that's the 3.5% to 4.3% for all Vermonters. So our margin there as a state is again wide, but estimated to be between 5.5% to 16.7%. So that's kind of our total headroom through 2022 from 2017. And so if I was just trying to estimate at a high level, so if the Medicare trend for the ACO were set at 3.5%, we would expect the all-payer growth contribution to be 0.6%. If we set it at 7.3%, it would be 1.4%, and if we set it at 10.4%, we would already have about 2.1% of growth in the all-payer, which that would mean that if the bottom end of our headroom is right, that would mean that the rest of non-ACO Medicare commercial Medicaid would all have to grow by 3.4%, which makes me a little nervous. That doesn't seem like it's likely, but these things all add up, I guess is the point. So your decision, which is never an easy one, but is deciding on the trend rate to use in the benchmark. I think there are really three functional options. I think it's using the 7.3 that I'm recommending, using the maximum trends allowable, or going with a retrospective trend like we used in 2020 and 2021. The good news is I don't think there are any wrong answers there. The bad news is I don't think that there's necessarily a right answer, and that's just a hard decision to make, but I think they're all ones that we can live with as a state. But to inform your decision-making, we did receive one public comment on this topic, and that came from OneCare Vermont, and their comment agrees with all the uncertainty in the air and kind of cosigns on the idea that we should revisit the 2021 experience to make sure that we get that right in the calculation. And they expressed their opinion that the maximum allowable trend is the appropriate approach, so that we may maximize federal funds and provide financial arrangements to healthcare providers that are in line with Medicare Advantage. Unfortunately, there wasn't really a lot of... That was just kind of a statement. There wasn't any additional material to help me understand why they thought 10.4 was the right number or why making sure that healthcare providers are aligned in this kind of payment arrangement is the right plan, but that's what the comment said. So the staff's analysis about using the maximum trend kind of boils down to these points. One is that, again, with that 2% risk corridor, the maximum trend would increase the potential. Savings are lost to the ACO by something in the range of $200,000 to $300,000 total. My guess would be it'd be closer to the $200,000. So in the grand scheme of things, not a lot of money that would be kind of left on the table here. I also want to point out that the agreement does say that our duty in setting these benchmarks is that they are set in such a way that enables us to achieve the financial targets in the agreement. So as I was trying to say before, using that max trend does make it a little bit more uncomfortable to meet those targets. I should say that additional savings generated by the model still counts for the total cost of care. So it would only probably add about a 10th of a percent to our growth rate, but it's not like we don't have to factor in those additional funds in our accountability. And I just haven't seen any other evidence that suggests 10.4 is a reasonable estimate for the growth from 2021 to 2022. The call letter, which again was generated in January of 2021, is the only place I've seen numbers that high. And I worry that taking advantage of that probably too high estimate just would jeopardize some of the trust that CMS has in us in making decisions that are both good for Vermont and good in the grand scheme of things. So I guess I worry that much more federal money might be left in the table if we jeopardize some of that trust down the line. So my recommendation, same theory, but a different number. So recommending that we follow the Medicare premiums that were set and use a rate of 7.3 percent in both the non-ESRD and ESRD benchmarks and that we should include in advance of the full amount of the blueprint for health payments of $9,073,982, which again the ACO would be accountable for when the savings are calculated at settlement. So that was a little fast. I'm sorry I had too much coffee this morning. Thank you, Sarah. Are there board comments or questions for Sarah? I just have one quick one, Sarah. Could you just go over, assuming that we accept the staff recommendation of a 7.3, can you just go over it? I remember it was in your original slide deck and I wish I had it brought it with me today. But sort of the caveats should Amacron exceed even the most abysmal expectations that we already have for them. You know, what were some of the off ramps? Can you just go over that again? Yeah, so one is again revisiting our 2021 experience to make sure that if anything super unexpected happens these last few weeks of 2021, we've accounted for that. Two is to monitor the trends that we're seeing and developing and the main ones we're worried about, where I'm worried about is what additional uptake of Medicare Advantage does to the remaining population of traditional Medicare fee for service beneficiaries. There is the kind of increased severity of care needed to address the people who are presenting for care after deferring care that should not have been deferred. There is the need to refer care out of state that normally wouldn't be true due to our capacity limits. And finally there, yeah, if COVID comes back into play, we would need to make sure that the target and baseline are adjusted accordingly. So, you know, and if things are looking really nuts, there's nothing to say we can't amend our proposal and go to a retrospective trend. Great, thank you. I just wanted that brought back up. Thank you, I appreciate it. Yeah, no problem. Other questions or comments for Sarah? Yeah, I have a question. I'm just trying to get some perspective on the slide. It might be a couple of before here that's up on the screen having to do with the 2% corridor and the $200,000 negative and $300,000 positive. I'm just trying to get out this one here. So it's savings and losses, 200 to 300. If that were the numerator in a calculation, what would the denominator be? Because your characterization of that is that it's not a lot of money. And I agree in the scheme of things it's probably not a lot of money. But just to get us, so if I do the simple math of saying, $250,000 is 2% and do the roll the math out to wherever that comes out to is probably quite a few million, is that fair? So to be clear, this is the sum total of using, if you move from a 7.3% trend on the benchmark to 10.4% because the ACO is using such a narrow risk corridor, in total it changes by this range of $200,000 to $300,000. In terms of leaving federal money on the table, it doesn't seem like a lot of money. So the total risk corridor right now we're looking at, so this is another way to think about it. So at settlement we're estimating the up or down risk for the ACO would be $10.2 million with a 7.3% trend and it would be $10.5 million if you go to the 10.4% trend. So that's kind of the additional risk, additional potential savings that would be potentially not maximized. Okay, thanks. Okay, other board questions or comments for Sarah? If not, we'll open it up for public comment. Does any member of the public wish to comment on the 2022 Medicare benchmark proposal that's in front of us? So I do see a hand raised, Vicki Loner. Vicki, are you there? You're on mute, Vicki. Yeah, I know I need a t-shirt. You're on mute. So thank you, Chair Mullen and thank you, Sarah, for all your hard work in trying to get to a reasonable trend rate calculation for the all-pair ACO model. We still continue as we noted in our letter, feel like in order to maximize federal dollars, and I'll just note that even under the current corridor, the amount of savings and loss that the ACO might be able to recoup will almost be completely depleted by the funds going out to the Blueprint and the SASH program. And so that's a factor in this is that there needs to be some sort of reward opportunity that's left on the table for those providers that are willing to take both financial and clinical risk in a program. The call letter and the APM agreement does allow for the 10.4%. And if at any time it would make sense, especially since there's so much uncertainty, to allow for that type of growth rate, it's now our federal and local health systems are in crisis. And I think they need the greatest degree of certainty that they can have right now. I would also hate for this program to become way less attractive than other off-the-shelf Medicare programs or Medicare Advantage programs that might offer better financial alternatives to this. So again, all my comments are in line with the public comment letter that OneCare wrote and we continue to maintain our position of maximizing the rate as we move forward. So thank you. Thank you, Vicki. Is there other public comment? Jeff Thiemann. Good afternoon, Mr. Chair. Thank you. I just want to say appreciate you and the board recognizing the staff recommendation to underline Vicki's point a little bit. As Mike Del Treco commented a week or two ago, I believe we do see the logic of maximizing the federal dollar, especially at a time when hospitals are managing so much uncertainty and the labor costs alone that are creating a lot of that difficult space. And then just also to sort of agree with what board member Holmes said about the need to monitor changes given everything that's going on and all the uncertainty that could still be coming so that we could adjust if circumstances call for that. But I think hospitals need to be properly resourced to make reform happen. And if we deprive them of that oxygen, anything that sort of limits their ability to get out of the pandemic and invest in reform, we should think carefully about. Thank you. Thank you, Jeff. Next I'll call on Mary Alice Bisbee. Mary Alice, you're muted. Okay. Hello. I've never commented before, but I just think that expecting this 10.5% increase is ridiculous. And I am just not for continuing the contract at all. And I just think that Medicare Advantage is raising rates on people. And maybe it's not costing the state more money, but it's costing individuals more money. And they don't even know it. That's my comment. Thank you, Mary Alice. Is there other public comment? Is there other public comment? Hearing none, going back to the board, does any board member wish to make a motion at this time? I'm happy to make a motion. But before I do, I just wanted to talk a little bit about how I'm thinking about this. So where I've been mulling over the last week is between the 7.3 and the 10.4 trend, because in general, I do think it's important to maximize federal funding, especially in a time of uncertainty. However, the 10.4% while it is allowed is not particularly mathematically, actuarially, or factually justified that in terms of the evidence that I've seen. If there was additional actuarial or other information that one care had, I wish that they had provided that to us, because that would give us a way to justify with facts that trend. But that trend assumes that the prior year trend was much lower. And we know that in our case, our providers actually didn't receive that trend. They received a retrospective benchmark. So because of those factors, I don't feel like I have a factual basis to go with the 10%. So that's my explanation. But I'll make the motion now, which is that I move that we approve the staff recommendation of the trend. Sarah, could you pull the slides back up so that I have it in front of me? Sorry, I didn't pull them up separately. It's 7.3 for both, but I'll grab it for you. Great. That's great. So the staff recommended trend of 7.3 for non-ESRD and ESRD ACO benchmark with the guardrails included in the proposal to assess the 2021 estimated experience with actuals and adjust if necessary, monitor 2022 closely to determine if the trend requires revision and ask that staff come back to the board, should that be the case, and ensure that the baseline and performance year have the same inclusions and exclusions in the total cost of care. And I would also move that we include the advance of the 9,073,982 for the blueprint in SASH programs. Is there a second? I'll second it. Is there further discussion? Yeah, generally, sometimes the argument for leaving federal money on the table is an easy argument to make, but sometimes there are kind of future downstream costs to that too. And so I just want to ask Sarah relative to Robin's comment about no actuarial evidence that justifies the 10.4 percent. Is that something that you have any insights on about? Yeah, so everything I've seen since the call letter is pointing to lower growth from 2021 to 2022. So again, that projection was released in January of 2021, so we didn't even have any 2021 experience to estimate what was going to happen in 2022. So that's what I thought the premium announcement for Medicare was the most recent actuarial evidence of what Medicare itself thinks it's going to grow at from 2021 to 2022. And my point, Tom, is if someone was able to say, well, our situation in Vermont is different, here's an actuarial argument or a mathematical argument for why this trend is justified given the Vermont specific circumstances as opposed to the circumstances under which the call letter was done, then that I would find totally compelling, but we don't have that. Other discussion. Just another quick question, Sarah, for you. I think the guardrails are so important and the monitoring and all of that that's in the motion. And I'm just wondering if you could just share a bit about the timetable on that, when we'll have an update on whether or not this 7.3, it was the appropriate, if that's what the board decides, or how does that work time wise? Yeah, sure. So around April of 2022, we'll be able to get a better handle on where 2021 landed. So that's the important first step. We'll have an inkling of what's starting to emerge in January at that point, January and February, which I think is where the nation will probably be hardest hit by the Omicron surge. So we'll have some early indicators there. I also think, I expect there'll be further deferred care in that period. So I think it's something that we'll have to do on an ongoing basis. And it's something that we partner with not only CMMI, but OneCare. I feel fortunate to have great working relationships on both sides on the data side of things. So that it's been very collegial and we worked well together on coming to reasonable solutions in the past. So yeah, I think if anything I could see coming before you in July and saying, you know what, I recommend a retrospective trend. I think we'll have a pretty good sense of how things are unfolding by then. Other board discussion? If not, and Robin, it was hard for me to keep up. My pin was dying, but I believe that, correct me where I have this wrong, I believe the motion in front of us is to approve a Medicare benchmark rate of the staff recommended rate of 7.3% for both non-ESRD and ESRD with guardrails built in place for possible adjustments and requiring monitoring by staff for those possible mid-year adjustments. Further, you propose that the proposal would include an advance of $9,078,982 in shared savings for the blueprint and sash. Have I got that correct? I believe it's $9,073,982. Okay, you're right. It's on the screen in front of me, so I should sit in my own writing. So all those in favor of the motion, please signify by saying aye. Aye. Any opposed, please signify by saying nay. Let the record show that the motion carried unanimously. Thank you, Sarah. I know it's been a lot of work and we appreciate it. And I know that no one will ever, there's never a situation where everyone is happy. And I know you've done your best to try to make sure that Vermonters are covered under this proposal. So thank you, Sarah. Thank you. So if you could take down the screen, we're going to move to the next item on the agenda, which is the 2022 one care Vermont accountable care organization budget and certification. And to tee that up, I'm going to turn it over to Marissa Melamed. Marissa. Thank you, Mr. Chair and board members and good afternoon to all. My name is Marissa Melamed. I'm the associate director for health systems policy and functionally the administrator and project director for the Oversight process for the board with me today is the full green mountain care board policy team led by Sarah Kinzler to assist with policy questions and discussions that might come up. Also Patrick Rooney had a finance for the GMCB and Russ McCracken staff attorney to assist us with legal and procedural issues as you prepare to vote. I'm going to go ahead and share my screen. There are great. Thank you. There are two documents as part of the presentation today. I think I can toggle between them as needed. We have a couple of slides and then the list of final staff recommendations, both of which are posted on the website under Asia Oversight and today's board meeting materials. I am pleased to be here today for the culmination of three months of in depth review of the FY22 budget for One Care Vermont. Our team has put together a set of budget conditions this year that we feel provides the right level of oversight within the broad authority of the ACO statute and rule by focusing on ACO performance, financial accountability for the organization and continued progress for a greater share of payments in value based arrangements. We have reviewed those conditions with you over the course of this month at several meetings and have noticed a potential vote for today's meeting. I'm not going to review each and every condition today. The presentation will be fairly short. I'm going to walk through any changes or highlights since last week. The agenda for the presentation is a quick summary of public comments that we received. I'll go through the final staff recommendations. There is board questions and discussion, public comments, then the potential vote and next steps for this process. So total comments that were received from 46 people, three of the 46 were received since the initial December 8 staff analysis presentation. All the comments are posted on the Green Mountain Care Board website. Just some broad themes of the comments that were received. There was support expressed for the value of One Care's data and analytics to providers, especially for population level insights and prevention initiatives, the value of care coordination investments enabled by One Care Vermont funding. There are also concerns expressed related to decreased population health management and mission related investments, concerns around One Care's leadership compensation, and just general concerns related to One Care's performance to date. I will note that I think we received two comments after the deadline of December 17th. As we always say, the board accepts and reviews public comment at any time, but those comments might not be reflected on this slide here. We'd like to thank, in particular, the engagement of the public on this topic, the quantity of comments that we received. It's always very helpful to hear what people have to say. And in particular, I'd like to thank the healthcare advocate who submitted comments and has a special status to ask questions, participate in the hearing, and receive confidential information. So we appreciate their collaboration on this review. We also received several comments, especially as we were trying to wrap up our recommendations directly from One Care Vermont. So the link to the final recommendations posted in several places. You can let us know if you have trouble finding it. I'm going to toggle over to that document. And you can use that as a visual or you can follow along on your own. Just a quick note about the highlighted information. This information is highlighted in gray. This is information that we have flagged that will be part of the FY22 reporting manual. This is the manual that the board puts together annually to keep track of all the reports that we require One Care to submit to us. Several of these reports are ongoing or not new, you know, don't pertain to new budget or conditions. We just wanted to note relevant reports in here. So it's not part of conditions that you'd be voting on, but we think it's helpful for the board and the public to see information that is reported. So like I said, I'm not going to read through all of these. We've been through them. I'm going to say a couple of highlights and anything that has changed since last week. The first one, there are no changes to this first condition that I did read through last week, but I want to make a quick note about it because it's new and generated a bit of discussion. This condition moves us to a monitoring approach that emphasizes comparison to peer organizations across the country. It requires One Care to invest in a benchmarking tool to measure performance against other ACOs, starting with Medicare as a test year, and then moving to commercial and Medicaid. The tool also will include identification of best practices. One Care will be required to report a dashboard to GMCB on key measures at least quarterly. And staff considers the benchmarking system as a tool for ACO performance improvement. This has been discussed and been in prior budget order conditions. We believe that it's a tool for both ACO performance improvement and regulatory oversight. Prior attempts to develop and implement a population health and financial performance dashboard through budget orders have focused on state-level data and state-level variational analysis only and have not provided the GMCB with a reliable tool for assessing ACO performance because it doesn't provide us any meaningful comparisons. So we're hoping that this recommendation will enhance that oversight. Moving on, the second condition is around the reporting requirements related to the first. Then moving to the second section, payer programs and risk. There are no new conditions or recommendations here since I believe our original presentation, so I'm not going to spend time on that section. The ACO budget and financial section, again, there are no changes since our presentation on the 15th. We did add a little bit more specification around what One Care needs to present at their revised budget in the spring that was discussed at last week's meeting. So I don't think that we need to review that unless there are questions. The major change from last week to this week is in the population health and quality section around the staff recommendation for the value-based incentive fund. So last week we presented two options to you. It was to increase the level of funding that goes to the value-based incentive fund or the ACO's total quality accountability program. And our final staff recommendation on this is that the ACO funds total quality accountability programs at a minimum of the 2021 level of 2.24 million. This includes the value-based incentive fund or other population health management investment programs linked to quality and outcomes such as payments tied to quality in the new care coordination payment model for 2022. After last week's discussion, staff finds that while the total quality accountability may be slightly higher when all payments are considered, more of that accountability has shifted to variable settlement dollars and pre-funded fixed dollars have declined. More timely all-payor incentive payments decoupled from settlement provides an additional incentive and additional cash for network providers that they are able to earn. Once payer contracts are finalized, the ACO will come back to the Green Mountain Care Board with their revised budget indicating the additional funding for this change. So that is where staff landed on that particular recommendation. Around provider payment models, I want to make a clarification around fixed-perspective payment reporting that when we noted here what's in bold that the staff continue to work to refine reporting and start rulemaking as previously instructed at previous meetings. I wanted to clarify that we are already working on specifying a format and methodology for collecting data about current ACO FPP levels and targets in the updated manual. So that's reporting that the ACO submitted a report to us in July. We've been working to refine that reporting so that that particular piece isn't lost in the reporting requirements. And with that that brings me to the end of the changes. Next I will turn it back to you Mr. Chair for board questions and discussion. Thank you Marissa. I'll open it up for a board comment or question. I have a question but I like where the staff landed on the VBIF. I think giving some flexibility in terms of how those whether that's in VBIF or other pre-funded sort of in real-time quality programs give some flexibility but also maintains that investment in quality. I guess actually I do have one question which is sorry which is when I was reviewing the final final this week it occurred to me that because last year we had set up the reporting manual through a condition in the budget that it might we might need to do that again since those budget conditions live for the term of the budget. So I was thinking of proposing that we add a just a condition to clarify that you know there will be a reporting manual and that that will be developed maintained and revised by staff just so that it's clear under it's clear legally that we've delegated that authority to do that. So I wanted to mention that so no one would be surprised when my motion includes it. Okay other board members comments or questions? Yeah I have a question. Once a motion is made on the overall budget I have two or three amendments that I'd like to talk about one having to do with FPP you know they're having to do with the cost shift and the third having to do with the health benefits the QHP health benchmark plan but I just I'm seeing that something got lost in the translation over the chaos of the last two or three days so if Marissa you could kind of screen up I think to your last slide on on the staff recommend yes right there. So I had we we had discussed that over the last few days and I was left with the impression that that language was language that I would offer as a second motion because it was consistent with with my first motion but and so I have an amendment prepared which I don't think we need to use now that says exactly those words in the shaded area. So I think between the conversations between Marissa and Sarah and Russ and I something got lost in the translation but I'm happy I'm happy to accept this as as it is and not not have a separate motion with that exact same language in it just in FYI. Yeah this particular piece Tom was just to clarify so the the bold there in the highlighted section is what we had last week where we said staff level work to refine reporting by refined reporting we mean what you have there below so that was already sort of part of the the reporting manual but I think I saw Russ just popped on to help us sort this out because we want to make sure we have it right what we need to put as a condition on their budget and what is simply a reporting requirement for reporting of data. Yeah no the language I had on the motion is exactly that verbatim but it makes no difference to me whether it's a separate motion or just here in the body of the staff recommendations that I think will be a little less busy for everyone to leave it where it is. Okay other board comments or questions not I'll open it up for public comment. Does any member of the public wish to comment on the one care budget and the recommendations that are in front of us and I'm going to call on Vicki Loner first. I'll get it right sooner or later so thank you Chair Mullen for a comment on the budgetary points I wanted to thank the board for putting in place some guardrails in terms of reevaluating the trend as we move forward I think the year has not closed out yet so it's really hard to project especially given the uncertainty that's going on and the state of COVID where we might land so we might be closer to that actual call letter of 10.4 so I do appreciate that and also in that the ACO does have many blind spots in its data and so we appreciate that the Green Mountain Care Board would be working with CMS to really evaluate where those trends are landing in in 2021 so I do want to recognize and appreciate that that's an important guardrail to put in the budget orders so thank you for that moving along to the budget orders the ACO did submit a comment letter we still hold true again to those comments that we made in the letter we do believe that it's a good idea to have benchmarking data for the ACO and we believe that that benchmarking data should be at the approval of the ACO and not at the Green Mountain Care Board for maximum engagement and uptake this has to be something that is provider led and not led by regulation so that is our main comment on this is the goals of the all pair model were to have provider led healthcare reform and I think you'll have a better uptake if you leave the final approval at the ACO level. In terms of the value based incentive fund we do appreciate the flexibility that has been offered in looking at other programs we are still in the process of finalizing negotiations with payers so adjustments might be made going into 2022 I would caution and have people calibrate that currently the savings and risk ratios are very low and that's intentional because there's a lot of volatility right now and we don't want to put the hospitals or primary care providers at risk by very high risk margins during a time of uncertainty and with that that means the risk and reward at the ACO level is much lower than it has been in previous years and so the ACO is actually investing more in population health programs than it will ever be able to get back to in that particular year so hopefully in years coming towards a future that will change but that's not the case right now and I just hope that is in the board members and staff's mind as we as we move forward during such a time of uncertainty so thank you to to Sarah and Marissa you have been working very diligently with our team and I believe that although we don't always agree on things that we come into the conversation with collaboration and openness to discussion so thank you thank you Vicki next I'll call on Mary Alice Bisbee thank you again and I do appreciate all the work you've been doing on office in spite of some of my criticisms but I think one thing that I'm concerned about is the deferred care being used as a reason for making changes I think it's much more than deferred care I am very happy that you are going to have them pay for sash and other things I am a sash person who receives sash services in my house in my public housing so I just wanted to put that in there as something that I hope but I think that the state of Vermont could do this very well without one care and could pay for session could do with these other things without having a middleman who with value-based care is going to be getting they're going to be reaping all the profits on the on the side of the insurance companies and the ACO that's my comment thank you Mary Alice is there other public comment Kevin Mike Fisher here hi Mike go ahead so good afternoon Mike Fisher healthcare advocate a couple quick comments one is I appreciate and agree with the direction on benchmarking against high functioning ACOs I think that's a good move I appreciate the direction of the board recommendation on public health investments here and I always want to caution I we made a pop we wrote a letter to you and I don't want to repeat what I what I already wrote to you but I do want to say just on a high level that we continue to be concerned that the ACO is not engaging in enough of the both public health investment activities and intensive case management activities to have the kinds of outcomes that we're all looking for high-level concern thank you Mr. Chair you're muted thank you Mike next I'm going to call on Susan Aronoff Susan hi good afternoon everyone and thank you for all of the hard work you're doing under these circumstances and everything I just have a question and I'm not going to go through all of the staff recommendations one by one but just in general and maybe this is a question for Russ I'm wondering how you envision enforcing some of the recommendations like let's just take specifically the one on administrative expense it says something I don't have it in front of me but one cares administrative expense won't shall not exceed x what 15 million whatever it is this year in this year and so I'm just wondering because this admin administrative expense issue has just been kicked down the road you all know well for those of you who don't know your first order had a limit placed on it that was going to somehow be able to be enforced in the first year and then you kind of realized the difficulty of enforcing things in real time so you came up with this thing of I call it moving the goalpost of moving it to the end and saying okay the benefit of it however we're going to measure that has to exceed whatever these administrative costs have been over the years but so now I'm wondering I really appreciate I'm doing the compliment sandwich great to have the recommendation the recommendation the mandate I guess it says shall for the administrative expense and a couple other things shall not exceed x dollars what happens if it does that's my question and comment and everyone have a great holiday and really I think the amount of work your staff Mr. Chair has done on this is tremendous and thank you for the report you did on the public investment unfortunately I didn't see it till after and file my comments but I've seen it since and might file an addenda 37 million or whatever it was I have questions about it because I have some different numbers but that's a lot of money we need to know what we're getting for our money thank you Susan Russ are you prepared to answer a question on enforcement mute yeah I can talk about enforcement sorry this is the afternoon for the muted anyway my shortcut to unmute didn't work the board has authority under its rule to enforce its budget order and you know there's a process that we would go through to take remedial action starting with putting an ACO in a corrective action plan and if that doesn't work we can enforce the the board's order in court and through that process so I'm not sure if there was a different question being asked but but that's but specifically then I mean it it appears throughout the recommendations that these shells but specifically with administrative expense so they've gone over you wouldn't find that out till much later down the road what would enforcement look like a budget freeze like a staff cut like how would you enforce them going over administrative expense and I'm not meaning to be difficult I'm a recovering lawyer I've tried to imagine what enforcement would look like so I'm curious if you've thought it through what you think enforcement would be for going over this is a hypothetical where there's a variance in their actual versus their what they had budgeted is that what the question is this is specifically I could pull it up it's early specific number they shall not spend more than 15 million on administrative expense so let's say they come in and they report you oh a million and in April you know whenever you find out it won't be in real time well the first step would be that the board would have to meet and to have a discussion and determine if there's just cause for enforcement before we proceeded with that enforcement and so I think you're assuming in your question that there wasn't just cause for that variance and what would happen in that situation and so Russ I think if you put it in that framework maybe it would help and I think there's also we the board has monitoring throughout the year on the actual financial progress of the ACO so there is some tracking it's not being blind to what's actually going on and then getting to the end of the year to find administrative costs were significantly different than what was budgeted well I'll add here that we do require quarterly financial reporting of both the full accountability and the entity our gap level budget as we described initially and there is a new condition this year trying to find the exact number that we went over I think at the original presentation that one care has to be sure to provide updated projections for the year as well so we'll see the budgeted amount slash projections for the year so that is our ability to monitor that Patrick wants to add anything here he might bend the line but that's my it would be my response yeah I'm happy to this is Patrick Rooney Susan so we wanted those projections to be built into the quarterly reporting for partially for this purpose and partially for our own monitoring that we know projections can change and can be relegated to the dustbin depending on activity that can occur over a quarter but still the point there is that it begs the question to be asked on a regular basis and communications with one care about what they anticipate on ending their year at as far as administrative expenses and it's something that we focused on over the last couple of budget cycles both last year and this year so getting those projections uh replying with questions that kind of attack those variances whether up or down to better inform this process and I believe we received the quarter three information from one care at about the time the staff was getting ready to present to the board so with that timing in mind it would it could play a pertinent part at this time next year in the budget process which would make it very relevant okay is there other public comment is there other public comment hearing none does any member of the board wish to make a motion I do yes oh you go ahead Tom okay um I'll try to be quick here uh so my first that I mean the three areas that I think are fundamental and um those are of uh the level of fixed prospective payments on the commercial side um the uh cost shift which is you know the ACO and their presentation to us mentioned the cost of shift twice and it was only in relation to the Medicare benchmark at 10.4 percent and thinking that that might be a windfall that would help offset the Medicare cost shift a bit um and the third is is the essential health benefits uh in the QHP plan now we can't we can't have much say um over I'll get to that in a minute so in terms of the FPP my uh motion is um to uh one care must submit a report to the board on its progress relative to its targets for commercial payer FPP levels that one care set in accordance with its FY 21 budget order condition 15 in any FPP targets set according to conditions in the FY 22 budget order and I my concern here um I think is underscored um by by the the data yet that we've had before us both in terms of the ACOs uh in terms of our staff presentation now I'm referring to slides 66 and 67 which I'll get to in a minute um but uh so let me just start by saying that the ACO stated in in their filing quote the pivotal first step in managing overall health cost growth is to transition the health system from one rewarding volume to one that rewards cost effective and high quality care that's on page 45 but on slide slide slide slide 66 and 67 what we see is that in terms of FPP's Medicare is at 51% of of their payments um Medicaid depending on traditional or expanded at 54% to 58% and and only uh and for commercial it's only 1.1% and as board members we saw through the um um rate review process that on a combined basis insurers were into fixed tax capitated fixed prospective payments at about a one one and a half percent level and so this just seems to me way out of balance and so last year we did uh have an order uh uh condition 15 to kind of take a ask one care to take a closer look at this and project out some targets with which they did and for uh calendar and and for fiscal year 2022 they uh hoped for a 10.9% commercial percentage in terms of fixed prospective payments um we also uh so starting at that point what all my order does or amendment does is just to say okay uh one care tell us you know uh you know later this spring they tell us how you're doing against that 2.9% benchmark that they put in place it's not our benchmark and so I'm starting at a very low point here of you know plus or minus one percent in terms of fixed prospective payments you know whether you you look at uh you the hospital percentage or uh through rate review etc um and just kind of trying to grow that to a mere 2.9% in fiscal 2022 2022 and then uh after that uh one care gets a little bit more steep I think they're looking at around 23% in fiscal 23 but I I just recall the the the differing positions um in our rate review hearings where one of the insurers basically said they had no willing partners to work with on fixed prospective payments and then during the hospital budget process we had had the head of the University of Vermont Medical Center coming in and saying I'm first in line just give me a a proposal that is actually sound and they would be first in line to engage um so uh so that's all this amendment does is based and it and it's complementary to the uh segment in the staff recommendations at the very end of their recommendations where they're looking really beyond fiscal 22 into 23 and 24 and setting up in in the manual reporting system so uh so this this amendment to me is transparency you know it's kind of uh you know we can whistle what was that phrase uh whistle by the graveyard of FPPs on the commercial end but but absent their full engagement um you know I I I think with the whole effort of health care reform is severely weakened so that's my motion it's uh very simple and uh uh Kara has a copy you keep saying how simple it is could you state it so that I know what your your motion is yep I'll do it again and Kara can put it up on the screen um so the motion is one care must submit a report to the board on its progress relative to its targets for commercial payer FPP levels that one care set in accordance with its fiscal 21 budget order condition 51 and any FPP targets set according to conditions in the F22 budget order because it's quite possible by the time we get into this late spring um in April that there will be some contracts you know for FPP uh in uh tied to the FY 22 budget uh 22 budget process so that's that's my first proposal is there a second I'll second for purpose of discussion but my question is I don't understand why this isn't covered by the reporting manual well my my my uh insight is that it's it's not in the reporting manual now this requirement for um uh the ACO to report on its commercial FPP rates right but staff have indicated they're going to add it so I don't think necessarily that you know they could have reporting on fiscal year 21 as well as you know whenever it makes sense to do fiscal year 22 so that no I I think that's fair insight Robin um there was as I said earlier some confusion because yeah before this motion here and that verbiage at the end of the staff recommendations was one big order and uh and uh our legal legal and staff kind of ended up dividing them and then in the division one of them ended up in the staff recommendations and and here I am you know with fiscal 22 but I um so I get your point um but you know come April come April I don't think there's anything specific that says that the ACO needs to report on their FPP relationships with commercial um for fiscal 22 I I'm not sure that's in the manual now so Kara if you are on this uh call if you could post the language that Tom says you have so that the public could see it so at some point I can open it up to public comment thank you board discussion on Tom's motion I just need a minute to I need I need to look back at the staff conditions so I'm gonna do that right now you can see that the the draft second motion is exactly the verbiage you know that is embedded in the uh staff recommend recommendations that you know between 18 and 19 the last two recommendations is there other board discussion and Rob and I can always come back to a board discussion after opening it up to public comment if that gives you more time I don't have any I mean in principle I think it's a good idea to learn more about what how OneCare is trying to you know increase commercial fixed payments and and have updates um I think there's a lot of things that are in the reporting manual that the that the staff are working on and it seems to me this is a great thing to include in that reporting manual and um you know maybe it's something for example that we could add to what is reported in April when they come back for the revised budget but in principle I don't have it I don't have any problem with this okay at this point I'll open it up for a public comment on the motion Mr. Chair before you do I think I can provide a staff clarification okay if that's helpful it's always helpful I think the difference is that we are going to have uh or we had already planned to have the ACO come back and report to us on the baseline FPP levels and their methodology for calculating that and the target that's a reporting requirement I think what's different is now that I see Tom's language in the his second motion there the parts that says GMCB staff will approve or modify and approve a commercial FPP target and seek twice annually reporting I think the idea that we will accept and approve those targets is what would be a condition of the budget Ross if you have any additions to that or if you think that I've clarified please jump in and I apologize if this got muddled yeah thank thanks Marissa I'm happy to jump in and but I agree with what you just said here that and there has been a little bit of back and forth and discussion around these two as additions to to the whether they go as part of the budget order or part of the reporting manual and I think we can largely do that in in either place what's covered under the first motion seems to fit quite well with in the list of items that one care is required to come back and present on in the spring in connection with their revised budget what fits in the second motion largely is can be covered in the reporting manual the specifically the the requirement to have staff approve or modify and approve a commercial FPP target with respect to to one care that seems a little bit beyond the scope of the reporting manual and that was the thought of having it as a budget condition how about functionally and then let me just make it make it clear though that the the language in forget my amendment for my motion for amendment the language in the staff recommendations is exactly that wording it so I'm reading I'm reading from the staff recommendations and it says based on this reporting Green Mountain Care Board staff will approve or modify and approve a commercial FPP target and seek twice annual reporting from one care on progress toward the target that's what that's what they want in the manual and it's exact it's the exact same language I had here so that's why I'm withdrawing essentially the second motion because it's extraneous if it's going to be you know as stated in the staff recommendations so let me just be clear that let me just be clear Tom that I'm hearing you say at this time you're offering motion number one on the document that's on the screen in front of us yes okay Marisa go ahead that may be where the error lies and Russ can tell me if not but I think functionally if you want us to just collect that reporting that we've already collected as in have a consensus report on where we are with FPP and where we want to go or where that where the ACO proposes that they're going and we just want to collect that information that's that's for reporting if you want to have them if you if you want to set a benchmark so to speak or a target on what they're supposed to meet and hold them to that as a condition of their budget I think that's the piece that needs to be a motion if I have that correct okay can I jump in when there's a pause yeah I had already opened it up to public comment but go ahead Robin sorry you can do public comment first if you'd like okay I only see one hand raised Mary Alice Bisbee okay I just like where this is going I I don't think it's at all redundant to put in things that are going to make it more more able for the for one care to comply with these requirements this is what we need and and it will help make any decision for whether we should ever ever have a contract with them in the future even for one year and I hope you're not going to vote on that today thank you thank you Mary Alice is there any other public comment on the motion that's in front of us which is the first motion that you see on the screen in front of you seeing none I'm going to turn it back to board member Robin lunch Robin thank you before I jump into Tom's motion I just wanted to mention to Mary Alice first of all hello it's good to see you and second of all we're we don't approve whether or not one care in the payers contract that is that is between the payer and one care so I just wanted to make that clarification what we're doing is doing a regulatory review of what the programmatic and budgetary ACO program is we don't have authority to say yes or no to the contracts that so I just wanted to to clarify that so Tom how about this is the friendly amendment could we amend staff recommended condition nine which is the condition which has the the topics for the presentation of the of the revised budget when they come in um what if we add a progress report on the commercial fpp or all the fpp levels for that matter into that presentation so instead of having it being a second a separate condition we just we make it part of that presentation so it's a little bit clearer about when it would come in everything goes full circle I mean in my experience this is where this conversation started and it evolved into the amendment that I put before you um and adding to the you know the the language here in this in the second motion it's not my language it's staff language and I just agreed hey look it looks friendly and compatible let's you know let's combine them so um taking the essence of my first motion and putting it in staff in as a as a as a letter under number nine I think is what you're suggesting that's fine with me I I just you know last year the um the condition 15 was something I drafted and it was just in a order to kind of begin to to get transparency on this commercial disconnect that I I feel I see during rave review and hospital review um and absent engagement serious engagement by the commercial folks the ACO to me is is its effort is is undermined severely so um your your substitute makes sense to me and that that's where this conversation started with staff wait you know way back when Robin could you restate what you believe the motion would be yes and Russ and Marisha should tell me if they see a problem with this but I would so I think the motion should be to amend condition nine to add a new topic l I guess it would be um which would be progress relative to the targets for the progress on commercial payer FPP levels and then we could let let the staff kind of wordsmith it beyond that maybe something like consistent with the reporting outlined by the staff yep is there any do you guys see a problem with that timing or anything like that does that make sense to you it makes sense to me okay so I think that would be my my proposal to amend Tom's motion Tom I believe that you've uh indicated that it would be a friendly amendment and let me just repeat it to make sure that both you and Robin and I are all talking about the same thing one care Vermont must submit a proposal to the board so the the motion is to amend staff condition nine which currently reads at its presentation of the revised budget and no later than April 30th 2022 one care must present to the GMCB on the following topics and to that list of topics we would add a report on its progress relative to uh its progress on commercial payer FPP levels as further defined by the staff and consistent with the reporting manual and is that fine with you Tom uh yes it is so um with that is there any further discussion on the motion so the motion in front of us is to amend condition nine to add L which would be uh progress on commercial FPP levels consistent with um reporting um as set by the staff is there any further discussion if not all those in favor of the motion please signify by saying aye aye any opposed signify by saying nay does a board member wish to make a motion at this time before Tom before you go to your next one can we just I want to I have a question for Russ and Marissa about what they were talking about in terms of your second motion I think that what would need to happen is that we would need to delegate authority for the staff to come up with that commercial FPP target I don't know that that has to be in the budget order per se but we would need to do that official delegation of authority I think that is the legal issue is that right Russ yes that's right do you wish to be on that Robin sure um so I move that um I move that the board delegate to Green Mountain Care Board staff to uh specify and determine a methodology for uh fixed perspective payment targets and um and I'm going to leave it at that and amend and to also include in the reporting manual appropriate reporting on those targets and again I will open it up for public comment I think it's a very similar discussion to what was just had but I don't want anybody to say they didn't have an opportunity for input does any member of the public wish to comment on the motion in front of us at this time and I guess I'm out of order because I never asked for a second is there a second comment is there a second to Robin's motion second thank you now we'll go to public comment is there any public comment seeing and hearing none is there any further board discussion this is uh Mike Barber can you hear me we can yes um so uh just the board does have the authority to delegate um things to uh any member officer or employee uh I do think it would be best to specify who position or person we are you are delegating to um Sarah Kensler for example or her position might make sense thank you for that good feedback Mike Robin would you like to amend your motion I would Sarah what's your title because I won't remember director of health systems policy well that's easier than I thought thank you okay I would like to amend my motion to be clear that the delegation of authority would be to the director of health systems policy and is that okay with the seconder member Holmes it is is there any further discussion is there any further discussion if not all those in favor of the motion please signify by saying aye aye any opposed please signify by saying nay thank you proceeding onward um does a board member wish to make a motion at this time I do proceed okay so uh we're skipping over the second motion and looking at the third motion and uh that motion is and I'll give you some background after I read it in consultation with the board of managers recommend to the green mountain care board and actually sound analytical approach that the a co can use to annually provide an estimate of the incremental growth of the Medicaid cost shift in the effect of such growth on aco Medicaid benchmark trend rates relative to aco Medicaid provider costs um to me uh the cost shift is a major undercurrent in Vermont's healthcare financing arena and a negative one um its scale is huge um estimates for 2021 just for the hospitals is 264.6 million dollars in Medicare cost shift which we can't do much about and 252.2 million in Medicaid uh dollars uh shifting on onto commercial payers um it's important to understand how it is it's important to understand and I don't think we have an understanding yet as to how the cost shift flows through the aco which it does um it's uh you know the impact of on Medicaid providers is something that I don't think there's a clear understanding of the impact on Medicaid and commercial total cost of care is something that that we don't have a clear picture on um and it's uh you know if we do move and are moving toward uh um the uh kind of a management approach having to do with comparing ourselves to uh best you know best acos in the nation it's important to understand uh when uh you know the impact of the cost shift on Vermont's metrics relative to to um uh other aco metrics we've also seen that um you know we've spent a lot of time with the burns report for example you know that took a fairly good look at um uh the cost shift of H uh HSA by HSA or hospital per hospital but I but in terms of its of its relationship with the aco um it's not clear um let me so the question in is why why did and uh you know I kind of like put this in the context of in consultation with the board of managers and I did that because I I view this as much an organizational effort as well as a technical effort um and I think that the board of managers is a group of people that are they're they're very talented um they are ones that that have a vested interest in in the members of the board of matter is in fixing the cost shift um uh dr brumsted although he's not the head of the aco anymore has twice written letters to diva you know kind of talking about the cost shift and and and its negative effects um and the talent is there if you remember during the hospital budget process uh UVM medical center uh was fairly clear at profiling the impact of the cost shift on their their request for a charge increase so I think the talent is there and the vested interest is there and um um and if a method can be found uh to to measure this uh in in criminal growth and its impact on medicaid a provider or effect on medicaid provider costs um the the providers in vermont and the members of the board of managers all will be uh better you know in a better condition so so a is technical effort to get a window into how the medicaid cost shift flows through the aco and b is to engage that with the board of managers who both I think collectively have the talent to take on this this effort have the um have the vested interest to take it on and um so that's my hope is is to start a process that that allows us all to learn how the cost shift flows through the aco so tom well first follows her second I'll second so we can have a discussion about it it makes sense so tom I would my first question to you would be the green mountain care board annually prepares a cost shift report and can you just tell me what it is that you think is missing in that report that would come from this motion or is this just trying to shine another point of light on a problem that we all acknowledge exists no I I think it's different um it's it's more surgical that the the uh the cost shift information that we put out is just for hospitals and it's at a grand scale um here at the aco level you have um a large portion of the aco's attributed lives or medicaid folks you know and therefore their benefits are you know I don't know how it flows through the the medicaid rate but my guess is that the cost shift is embedded in the medicaid rate yet in terms of the commercial payers very few as we very few commercial payers um associated with the aco so yes there is a cost shift within the aco it's not parallel to the kind of the larger healthcare environment where that shift just goes on to the commercial um so internal to the aco there is a flow of the cost shift and that's something I think that we need to understand just because it's it's it's it can sap the aco of its success the aco could be successful in saving money but it just gets siphoned off by the cost shift so I uh I I just want to I I want the aco to be successful I don't want them to be weakened to buy the cost shift um and I but I think we need to understand how the cost shift flows through the aco which we don't tom would you be willing to I mean there has been a lot of work done on analyzing the cost shift quantifying the cost shift you reference the burns data which was presented there's the annual cost shift report there's a payer differential report there are existing resources that have done some analysis on the existence of the cost shift I'm wondering whether or not you might be willing to accept a friendly adjustment which would be using existing data on the cost shift um describe the effect of the Medicaid cost shift on aco Medicaid benchmark trend rates relative to aco provider costs so in other words just suggesting that you know there is existing data they could certainly do their own internal analysis if they so choose but there's plenty of data out there and I'm wondering if that might be what you're really trying to figure out is what is the impact on the aco so ultimately that's what you really need how they which data resources they use um you know there are existing resources out there so potentially they might be able to use that and just report on how it impacts uh particular how does the aco Medicaid benchmark trend rate you know affect the cost shift within the aco for aco Medicaid providers I mean that that's a simplification and and consistent I I'm fine with that um but just I just I I I the my construct in my mind of this and this is part of you know kind of a having somewhat of a political background or an awareness is is you got to get a constituency uh to I mean a phrase in in my earlier career was don't agonize organize and I do think that the BOM is a good place to because of the talent it has because of the experience it has in having to deal with the cost shift at the provider level um it but if if you want to frame that in the context of using existing data that's fine with me I mean I I I don't want them to go out and spend a lot of money he's doing a technical analysis so um that's fine to me I agree with you there's a lot of information out there so am I taking that that you have accepted a friendly uh amendment from the seconder I'll always accept friendly amendments from the seconder okay is there further board discussion I guess what I would say is I felt like the payer differential report did answer this question so you know I hear you about the politics Tom but if the provider led reform can't lead themselves in a productive way to recognize the challenges like I don't feel like a condition that we put on is going to further that like um so I would let them figure that out on their own um so that's just my comment is there further board discussion if not I'll open it up for public comment on the motion that's in front of us and I'll call on ham davis first ham uh thank you Kevin um one of the things that I do with this issue is I try and explain it to my readers and I there's no way I can explain this the cost shift um the cost shift is an integral part of what's going on and is driven by the fact that's that government pays less than the full share of the cost the idea that you can just have you can just sort of wave a Tom wants to wave a wand and say go away you evil thing now I can't I cannot make any sense out of that the how is anybody supposed to take you yourself Kevin you wrote a letter to the Vermont legislature asking them to reduce the cost shift by um uh reduce the cost shift by increasing Medicaid payments to something close to the market value you got blistered from one end of the place to the other yes it was quite a love letter that I got back yeah I I know and and the thing is and so what you've got is you've got a big cost shift coming out of Medicaid and a smaller cost shift coming out of Medicare and the idea that you can just say we want this to go away is strikes me is silly I mean I and I don't think it's complicated at all I think this issue as it is is as simple as dirt if you just the if you've got if you've got a bunch of payers and some payers won't pay the real cost then the cost have to and you and you can't you can't destroy the system by you can shut the system down but then you don't have any health care so what what what what are we supposed to what am I telling help me out here people okay what how do you just take somebody on the street and explain the storm makes no sense to me this whole discussion is it sounds like a fantasy so um let me respond to that I I uh I hear what you're saying because we're we're deep in the woods as we are but I don't think we have to accept the cost shift at least the magnitude of it or the incremental growth of it as God given um there's there is a you know uh yeah I think for example but but but first I think we need a beginning to have we need an organized constituency you know that that does get organized and focused on trying to fix the cost you're never going to make the 252 million dollars of Medicaid cost shift go away but but if we can control its growth or if we can mitigate it over a five-year period I mean like for the benchmark you know we we give them last year's amount plus three and a half percent I mean what what what miracle would it be if all of a sudden diva was to say on Medicaid we're gonna we're going to take last year's reimbursement rates and increase them by by what they were and three and a half percent um that's something that is within the capabilities of state government um if if you look at their presentation to the legislature it takes about five million dollars in general funds matched with global commitment to increase reimbursement rates across the board by one percent so but we're not at that stage yet where where we have enough people um with an idea on how to mitigate the cost shift to to move the needle so um I I agree with you ham we're we're stuck in the mud but um I don't think we have to be stuck here okay I'm going to call on Dale Hackett Dale can you hear me and yep okay this all makes me nervous I'm going to try to use a very simple example the ACO has million dollars in cost I think it's saving five million so you're down to ten million dollars in costs it's all Medicaid however the revenue resources coming in is eight million dollars what have you got you're short two million dollars you're gonna by the time you subtract that have three million dollars in saving I think a piece got left out then you have to account for inflation because inflation is becoming quite significant in terms of what its effect can be um I've seen some recent examples where inflation actually completely washes out any savings whatsoever um and that's extremely disturbing it's so concerning because I approach it the wrong way and how I try to want to take that eight million and turn it into ten million I can be and end up asking the lowest income in the Medicaid population be more incentive based on their income they live on than somebody at a higher income this gets very problematic I'm always excited to hear this discussion I'm always nervous about coming up with really bad solutions Tom that's some of what you were trying to get at I know it's more complicated but and uh one comment can't get to the occasions you're cutting out Dale you're cutting out oh sorry did you have anything further to say Dale that's a thank you you're welcome is there other public comment Mary Alice Bisbee yeah I just wanted to to say that the way that the commercial insurers are getting money is by up coding I don't know if you folks know anything about up coding but that's how they're getting their money and for Medicare people like myself I'm paying a whole lot of money for my co-insurance I don't have Medicaid but um you know when you're you're paying $239 a month for your co-insurance through United Health Care which is the most the best health insurance company for their profits if you're on in the stock market I think it's important to remember these things that we do have different levels of of income and that we do owe something to people who don't have enough money to buy insurance that's it thank you Mary Alice is there other public comment hearing none I'll go back to a board discussion is there any further board discussion on the motion in front of us I was thinking that maybe we could just simplify the motion in front of us again is that all right there's another second friendly okay I'm wondering if if Tom this would would be satisfactory to you in the reporting manual this would be in the reporting manual describe the effect of the ACO Medicaid benchmark trend rate on the cost shift and it doesn't matter where the we're not going to prescribe where the data comes from or what analysis they do but just the outcome you want is you want to understand the impact of that benchmark trend rate on the cost shift so we ask them for that yes I I I mean I don't think we have a clear vision as to how the cost shift flows through the ACO so but I'm interested in that as a technical matter but also interested in it in terms of giving hope to people that and providers etc that are negatively affected by the cost shift you know that things can change and so that's kind of but I what the direction you're going just doesn't is consistent with that so just to be clear I believe what I think the motion is is in the reporting manual describe the effect of the Medicaid cost shift and the effect of such growth on ACO Medicaid benchmark trend rates relative to ACO Medicaid provider costs is that correct I was literally going to simplify it too in the reporting manual describe the effect of the ACO Medicaid benchmark trend rate on the cost shift okay so let me repeat that back in the reporting manual describe the the effect of the Medicaid cost shift well I was going to say of the ACO Medicaid benchmark trend rate on the cost shift okay and Tom is that agreeable to you I just want to understand it so um and I know this is hard to do um I the machinations I went through writing the motion you know I appreciate what you're trying to do Jess but so you so the Medicaid so what you're saying is the impact of the Medicaid trend rate on the cost shift I would think it might be the other way around the impact of the cost shift on the Medicaid trend rate because my guess is that embedded in the in the Medicaid trend rate is the cost shift so you know if you can take the Medicaid trend rate and break it down pull it apart in terms of you know how much of it is shifting cost shifting onto others and how much is is there to cover costs um that makes sense sure so it's just be to reverse those two words is there further discussion not knowing one way or the other if this is going to be a unanimous vote I'm going to ask legal to call the names thanks thanks mr chair I'll call the uh do a roll call vote in alphabetical order uh member holmes I'll say yes uh member lunge no uh chair mullen no and member pelham yes okay uh with only two with only two yeses that doesn't pass i'm sorry that's your prerogative mr chair yeah let the record show that the motion failed tom do you have another motion yeah one more um i'll try to be as quick as i can on this one i i it's it's the longest motion i don't know how it got this long but it's the simplest concept is that there's a one a once not on a lifetime but there's a once in a rare event that we get to take a look at a um healthcare plan that serves a distinct segment of our population in terms of the individual and small group you know populations and uh the legislature has set us on a trail to take a look at the um essential health benefits benchmark plan which for remod i think was adopted back in 2014 and kind of predated um a lot of the healthcare reform efforts that have unfolded since and it and i you know that the report um from dfr and other stakeholders is due jan january 15th and i just thought it would be helpful uh because during the hearing when i asked whether not one care was engaged uh in as a stakeholder in the um essential health um benefits benchmark plan review the answer was they weren't at that point in time i don't know if they've they've done so since but at that point in time they were not engaged and so it seemed to me a disconnect between an effort that was going to structurally change or may structurally change the benefits available to the qhp population which in terms of our attributed lives is 30 000 lives to have have the aco staff that is concerned about population health and prevention disconnected from that effort and so the the the purpose of this motion um and i'll read it if you want me to the purpose of this motion is to make sure that connection is in place and that we as a board benefit from the aco's insights as to the uh recommended changes or not changes um in the in the benchmark plan i think it's important to state your motion all right to ensure recommendations for revisions to the remark h uh essential health benefits benchmark plan support the aco strategic plan to reduce cost growth or improve the quality and overall core care of enrollees in the individual and small group markets within one week following dfr's presentation to the board recommending changes in the vermont's essential health benefits benchmark plan one care shall submit a report to the green mountain care board that addresses whether the proposed essential health benefits benchmark plan is appropriately aligned with vermont's health care reform goals of cost and quality regarding population health and prevention that's set forth in vermont all pair accountable care organization model agreement and the department of health state health improvement plan 2019 to 2023 and identifies which revisions enhance or detract if any from the aco's efforts to enhance affordability and improve population health and prevention is there a second is there a second so i'm not hearing a second so unless someone speaks up i'll consider that the mission is filled tom do you have another motion no i'm done okay does any other board member have a motion i do and i will just briefly i just want to explain that the reason why i was not interested in seconding the EHB um robin if you just hold up a second whoever 802 793 um i don't have the rest of their digits but if they could silence themselves great thank you robin go ahead sure you know i think one care is welcome and i do welcome them to submit submit a public comment in the EHB process but i personally didn't want to prioritize one stakeholder over all of the stakeholders that are involved in that group it's i hope also that they are participating and i do hope they submit a public comment but i wouldn't require it so that's just you know sort of my thinking on that but i appreciate the spirit um so what i would like to do is move um to accept the staff recommendations as uh presented in the December 22nd uh 2021 document and amended today um by our previous motions uh and to add uh an additional condition um which would in codify essentially the GMC reporting manual process and and i i think it would probably be easier to just ask staff to uh create that condition based on the understanding that the ideas that uh we would have one care submits reports and information in in accordance with the reporting manual which would be developed maintained and revised by staff and in scope of the rule and the law is there a second second is there discussion on the motion i'll open it up to a public comment is there any discussion on the uh any public comment on the motion in front of us seeing and hearing none i'll throw it back to the board for any further discussion if not the the motion in front of us is um i believe the final motion um which is adopting the the the staff recommendations as amended through the earlier motion of um member pelham and adding um the um reporting manual language as specified by member launch is there any further discussion hearing none all those in favor of the motion please signify by saying aye aye any opposed please signify by saying nay but the record show that the motion carried unanimously marissa sarah and team um i know you've put a a lot of hard work into this and uh it's truly appreciated and uh thank you for all that you do um every day on behalf of our owners with that is there any with that is there any old business to come before the board kevin ham has his hand raised oh this is just a plea for mercy kevin can you say whether the whether the the vote that you just took um establishes changes the aco budget in any way in terms of the actual money that goes to them it changes um the amount of money that they will have to expend on um initiatives like um um quality i'm not i don't think it provides them with any additional revenue if that's what the point you're trying to make yeah i'm just trying to find out whether it i don't and the press needs to know this too they have a budget did the budget get did the budget get passed or cut the budget got passed with conditions that um required them um not to cut expenditures on um public health and quality as had been proposed well that that that that's fine i any budget can have conditions in it i just wanted to know whether it was actually whether an actual cut was made i not that there was any reason to i just wanted to see that and and trust me any reporters have to put the story out today about this will want to know that question thank you very much marissa did i miss something in my answer no i don't think so mr chair if i may the only thing that i would add is that in the spring once the contracts and attribution are finalized we we as as required in these conditions one care will be required to come back before the board and to provide us with an updated revised budget so the numbers that you see in the spring will be different based on what those final contracts saying what the final attribution is so i i just want to make it clear that that that change is anticipated and and will be based on kind of whatever the final the final contract say kevin that was a hundred percent clear i got it we'll have to have sarah answer your questions and not me him kevin no good deed goes unpunished you're finding that out buddy yep okay is there any new business to come before the board hearing none um in these dark days of the pandemic um there's a lot of concern and in a lot of um um reasons that someone may wish to find unhappiness but i just want to say that even in these dark days there's a lot of good things that we see in people we see it in all the providers that are around us and we see it when we hear news like today where the FDA has approved the emergency authorization use of the um Pfizer treatment drug we see it in some promising news articles about the possibility that um the army is close to um developing a vaccine that would actually cover the full spectrum of coronavirus and so there are so many things for us to be happy about so many things for us to be happy about here in vermont where vermonters look out for their neighbors look out for their loved ones and especially in these holiday times you know be kind and to continue a tradition at the green mountain care board if i can find the little button which i probably won't be able to probably won't be able to happy holidays everybody best wishes for a great holiday and for a much better 2022 i move we adjourn a second it's been moved to adjourn all those in favor please signify by saying aye hi hi hi happy holidays everyone be safe happy holidays