 All right, it looks like we have everyone. I'll call to order the Green Mountain Care Boards meeting of December 6th. Today we have three agenda items. We have the Green Mountain Care Board staff in the Office of One Care's fiscal year 24 budget. And we have potential votes noticed on the Medicare only ACO fiscal year 24 budgets for lower health and vitalize health nine. Our health policy project director, Michelle Sawyer and our staff attorney, Russ McCracken will lead those presentations. And we'll have public comment after the one care presentation and then a second round after the lower health and vitalize presentations. I'll turn to our executive director, Susan Barrett for her report. Mr. Chair, why don't you remind folks about some public comments here at the office right now. I also just remind you to accept public comments 365 days a year, but we do take the opportunity to make special public comments so that the public can share their views with the board ahead of a decision or a vote. So a new one that we just posted yesterday was the Brattleboro retreats budget submission. This is a new duty for the board and that they have their FY24 hospital budget review and materials that are posted on the board and we'll be reviewing that on Wednesday, December 20th. We ask that folks share those comments so that they can be reviewed by the board and if you could get those in by December 18th. If you get them in a little later, that's okay but we are trying to have a time limit so the board can see those before they make their decisions. We also have an ongoing public comment period for one care Vermont ACO budget submission and certification and we would like to have those public comments into us by Friday, December 15th so that the board can have those before their potential vote which is scheduled for December 20th. And then we have two ongoing public comment periods on some work we're doing at the state. The first one is the Act 167 community engagement work. We finished up our first round of virtual engagement meetings and getting ready to go back out later this next year, early spring to meet with community members in person but we are accepting any public comments on that work and again, thank everyone, providers and the public for your robust participation in that work. And then lastly, we are accepting public comments on a next potential all payer model with CMS. Any of the comments that we receive, we share with AHS, Agency of Human Services as they are leading the negotiations on that model and the work on the current model. And I just also remind folks to just check out our website for our community meetings. We have a couple of days that are starting early today. So just be aware of that people. And with that, I'll turn it back to you, Mr. Chair. Thank you. There may be times I have to go off camera. I've lost my temporary office that I was using and my internet might be a little iffy at times. So if I do, that's why I apologize. It helps with the bandwidth. We have meeting minutes from November 29th, 2023. Is there a motion to approve the minutes? So moved. Second. All those in favor, please say aye. Aye. Aye. And the minutes are unanimously approved. And is Michelle Sawyer here? Yes, I am. Hey, good morning. Remind me, are we doing one care first or the Medicare only ACOs? Yes, we're looking at one care this morning. Okay, great. All right. So the staff today will go through the presentation that they have and their analysis of the budget and the information we've been receiving over the last month or so. And the board, I think we'll vote on this. I think around December 20th is when we're planning on it. The staff will have a series of options for the board to consider and think about in advance of that, which I think will be at the end of this presentation today. So thank you, Michelle and Russ and your team and Angela for all your great work on this and I'll turn it over to you. Thank you. Good morning, everyone. Thank you for being here. All right, let's dive in. So here's the agenda for this morning. We'll do an introduction and background. We'll touch on some public comment that we've received to date. And then we'll get into the good stuff. We'll look at one care for months budget. We'll look at their budget targets, financial and performance review. And as Chair Foster mentioned, there's some options that will be discussed. Of course, there'll be time for board questions and discussions as well as public comments. So I'm gonna hand it over to Russ to give us an overview of the board's authority when it comes to the oversight of accountable care organizations. Thank you, Michelle. I'll speak about the board's oversight ACOs broadly and then some of the specifics around the review of certified ACOs like one care for month. Generally speaking, the board's ACO oversight breaks down into two different functions. The first is certification, which is required initially for any ACO receiving state Medicaid or commercial payments. That happens once and then it's reviewed on an ongoing basis at least every year. And the staff is working on that process. The second is annually, there's a budget review for each ACO and that takes place now in the fall and the board will vote to modify or approve a budget before the end of the year. So next slide, Michelle. In looking at the budget review for a certified ACO like one care for month, we look to the board's ACO oversight statute, it's ACO oversight rule and then the all-payer model agreement. And the specific standards that have been adopted by the board reside in rule 5405 says for a certified ACO with more than 10,000 lives in the state. The board will consider any benchmarks established under the rule. The criteria listed in the statute in B1, I believe there are around 16 different factors listed there. Unlike the smaller ACOs, for larger ACOs the board covers, the board doesn't have discretion as to which factors it considers. The rule says the board shall consider all the factors. The rule also says the board will consider elements of the payer-specific programs and applicable requirements of 9551 or the all-payer model agreement. And then lastly, any issues at the discretion of the board. And also as set out in the rule, the ACO has the burden of justifying its proposed budget to the board. I know that all the board members have been through this process before for OneCare, but hopefully that's a somewhat useful, if very high level overview of the standards in the process set out into the statute and rule. Yes. So let's just take a look at the timeline as far as OneCare's budget and certification for FY24. The board issued the budget guidance back in July. We received OneCare's certification eligibility verification material September 1st. And like Russ mentioned, the staff is still working on that. OneCare submitted their budget October 2nd. We heard from OneCare Vermont at their hearing on November 8th. And then last week we heard from the payers regarding 2022 financial settlement and quality performance. And then today we're here to talk about the staff presentation for OneCare Vermont's budget. Next week, there's the potential for some deliberations on the budget. And there will be the FY24 Medicare benchmark presentation. On December 20th, there's time for a potential vote for OneCare Vermont's budget. And there's a potential vote on the FY24 Medicare benchmark. And then throughout 2024 and into 2025, the Green Mountain Care Board will monitor FY24 performance against the budget and conditions. So let's look at some public comments. So as mentioned by Susan, the public comment period is still open. It is open through December 15th and we welcome any and all public comments. Thus far we've received 12 public comments and here's some themes that we're seeing. So we hear about the value of OneCare's improved health outcomes, higher quality care, lower cost and enhanced coordination of care, the value of care coordination and strengthened partnerships with local care organizations. We heard concerns about access to care and long wait times to see providers. We heard about concerns about the cost of healthcare in Vermont and concerns about the effectiveness of OneCare, the loss of Blue Cross Blue Shield and increasing executive salaries. The healthcare advocate also shared a public comment which I would like to review. So they asked some questions. They're questioning if OneCare is providing sufficient value to Vermonters given its cost. They question whether OneCare's approach and place in the overall healthcare reform effort could achieve progress on the goals of the all-payer model. And if OneCare will be able to help achieve Vermont's healthcare reform goals. They expressed concerns due to commercial insurance rate increases in Vermont and the fact that it now, they now far outpace the United States average. They're concerned that Vermont's rate of under insurance among Vermont's privately insured residents has increased from 27.3% to 44%. And Vermont's hospital adjusted expenses per inpatient day are now growing faster than the national average. They expressed they felt there was misrepresentation of the NORC evaluation to the board, the HCA and the public. They expressed concern around declining population health management expenditures while observing increasing expenditures on consulting and payroll and concerns about the purpose and benefits of Arcadia. The healthcare advocate provided some recommendations to the board. Those three recommendations are requests, they are requesting that the board reduce OneCare's purchased services line by 50% and evenly reallocate those funds to non-hospital owned independent PCPs to improve primary care. The HCA believes that such a change is warranted because OneCare has not provided evidence of why this amount is needed and that there is substantial evidence that independent primary care practices provide high quality and comparatively lower cost and Vermont has historically under-invested in primary care compared to the rest of the country. They also request that the board and its staff conduct a comparative analysis of return on investment of OneCare's activities to non-Chittenden County based HSAs compared to Chittenden County HSA. And they request that the Green Mountain Care Board and its staff conduct an analysis of OneCare's impact on affordability, health outcomes and access to help inform whether OneCare merits inclusion in any future all-payer model. All right, so we will get into OneCare, Vermont and the FY24 budget targets. So how, where we've been heading with these targets. So the FY22 and 23 budget order conditions reflected a focus on data-driven monitoring and oversight. There's really a focus on ensuring that the ACO's management drives continuous improvement consistent with high performing ACOs and that it supports achieving the state's health reform goals. This approach continues and it led to the development of the budget targets in the FY24 budget guidance. As Russ mentioned, the board authority to set benchmarks, we use the word target in this case because the term benchmark has several different meanings in this world, but so for clarity, we're calling them targets, but this is outlined in rule 5.402. The board may establish benchmarks for any indicators to be used by ACOs in developing and preparing their proposed budgets. They are really intended to signal to the ACO what the board would like to see in their submitted budget. The board developed seven budget targets for this year and there were two placeholders that were included as part of their guidance and here's just a quote to explain how this works. If the ACO's proposed budget varies from the budget target, the board will review the ACO's proposed budget and support for varying from these targets in its FY24 budget submission using the factors and criteria set out and statute in rule. For all budget targets that are met, the ACO should expect less analysis of the area of the budget from the Green Mountain Care Board and staff. So in other words, these budget targets are not binding. There was no requirement that OneCare had to meet any of these targets. There's a lot on this slide, but I wanted to have all of the targets and their status in one place. We will take the time to go through each one. So just briefly, targets one is at least partially met we're waiting on additional information. Target two was met. Target three and four were not met. Target five was met. Six and seven were placeholders that did not end up being developed. Eight was met and nine was met. So we'll walk through, we'll start with target one which is the FY24 commercial benchmark trend rates must be consistent with the ACO attributed population and the Green Mountain Care Board approved rate filings. This target was met at least for the MVP payer program and it's self-funded is to be determined. So this slide reviews all the payer programs trend and how the payer programs trend and benchmarks are set. We're focusing on the MVP and QHP and the self-funded payer programs for the sake of target one. For the MVP QHP, OneCare shared that their benchmark trend rates were consistent with the GMCB approved rate filing. And for the self-funded, the submitted budget explains that OneCare is analyzing the cost trends in more depth over the next few months and insights after this process can be shared as needed. And this table shows the expected cost of care for FY23 and the benchmark for 2024 as well as the budgeted trend from base experience for the payer programs. Honor to target two, OneCare, so it, let's see. The ACO must use best efforts to meet or exceed the goals for reconciled and unreconciled FPP and identify and report specific obstacles to achieving the goals. So the goals for Medicaid were 55% FPP and commercial 24% FPP. These were goals that the board had set for OneCare. Was the target met? Yes, for FY23 and anticipated for 24, Medicaid is approximately, is over that target. It's over 55%. For commercial, it is zero. Just to be clear, this target is not that they meet the goal, it's that they use their best efforts to do so and report specific obstacles to achieving these goals. So even though they did not meet the target with commercial, they did report their best efforts and obstacles. They described that they continue to negotiate with commercial payers to implement unreconciled fixed payment models. Obviously, this is a two-sided negotiation and both parties must agree on the terms. The slide shows the expected cost of care in the columns from 2018 through 2024. And each column is broken into fee for service and then FPP and CPR payments. The blue represents the portion of the expected total cost of care that's fee for service and the green is that FPP CPR payment. And then the line is the percentage of the expected total cost of care that is in FPP. So you can see that it has varied quite a bit over the years. But for 2024, it looks like overall, 44.2% of all of the payments in expected total cost of care would be FPP CPR payments. And then this shows the targets and where one care has been over the years from 2018 through 2024. So if we start down at the bottom with the gray line, we see the commercial has been almost zero the whole time. There was a few years where there was a small amount of fixed perspective payments offered by a commercial program, but we're back down to 0% for 2024. And then the dotted green line represents that goal of 24%. The blue line is the Medicare amount of fixed perspective payment. There is no gold surrounding that. The green dotted line is the 55% goal for Medicaid. And you can see that the solid green line has been above that the whole time. So the FPP target for Medicaid has been successfully met. All right, so targets three and four. Number three was the ACO must hold 100% of the Medicare advanced shared savings dollars at risk at the entity level and not pass the risk along to the provider networks. This target is a continuation of a multi-year effort to have one care hold these dollars at risk last year as a glide path to this target. The board had one care hold approximately between 30 and 40% of these dollars at the entity level with the intention that this year they would hold 100%. One care chose not to do this. They are holding approximately 8.8% of those dollars at risk at the entity level and the rest of those dollars are distributed as risk throughout the network. The fourth target was to increase risk corridors for all payer programs above FY23 levels and the target was not met in this budget submission and the risk corridors remain static between 23 and 24. So regarding target number three, this slide shows budgeted risk from 2019 through 2024 and the percent of risk held at the entity level versus the risk delegated to the provider network. It's nice to look back pre-pandemic to see what these risk levels were and how they were significantly lowered during the pandemic. So for FY24, you can see that the total risk level is back up to pre-pandemic levels, but the OCV held portion of the risk is quite a bit lower still. For context, one care typically is taken on risk as a glide path to support HSAs who are newly joining payer programs. This was back in their earlier years when those HSAs were not ready to take on the full risk level in their first year in the program. And you can see in FY23 that one care's risk increased after they held a portion of those Medicare advanced shared savings dollars, but in then 2024 instead of holding more risk, they reverted back down to lower levels. This is for budget target four. These are risk corridors over time in the public payer programs. So you can see in the Medicare pre-pandemic, it was up at 5%. And then during the pandemic years, it was knocked down to 2%. And then the last two years, it's back to three. And Medicaid, similarly, at one point, we'd gotten up to 4%, but we're back down, then it got knocked down to 2%. And 1% for the expanded cohort. And now we've been at three for a couple of years now. So we had, like I said, asked one care to expand those for 2024. Target number five. The ratio of operating expenses to PHM or payment reform payments, which include FPP and budgeted bonus payments must not exceed the five-year average of 3.25. Is the target met? Yes. There, that ratio is at 3.1%. I know it shows the five-year averages off by a couple of hundredths of a percent here. But you can see over time what that ratio has been and where we are for FY24, higher than the years before, but definitely lower than 2018, 2019. Target six and seven. The board had considered adding targets for these areas, but the requested information from one care to inform these targets was not provided. So the board decided rather than set a target without the information that they would be left as placeholders. Target number eight. The ratio of population health management funding to the number of attributed lives must be at a minimum of the FY23 revised budget amount. Specific line items may vary upon any internal evaluation of the effectiveness of the individual PHM programs. The ACO, and then there's a second part to this. The ACO must propose a plan to increase the accountability of its provider network for quality. Examples for increased accountability could include adding in an adjustment to the hospital fixed payments for quality or increasing the ratio of the PHM bonus payments to base payments for primary care and community providers. Was this target met? Yes, it was. The population health management funding per attributed life is at $166 per life. And the staff found that the accountability for the providers was increased through increasing the ratio of the PHM bonus payments to base payments and the addition of network provider accountabilities to the provider contracts. So I just do want to note that the population health spending line does include the Medicare Advanced Shared Savings Dollars. There are different ways of looking at population health support. So just to be clear that those dollars are included in this ratio. Let's see. So you can see that it outlines the changes in the number of attributed lives over the course of the ACOs operations, the amount of population health spending and the operating expenses in each one of those years, and then calculating how many dollars per attributed life were spent on both population health spending and operational expenses. And for the sake of this budget target, we are looking at that middle row and the column on the right, that $166. is higher than the projected 2023, which is 134. So they met this budget target. The second half of that target was around increasing accountabilities. So this reviews the network accountabilities that OneCare introduced to their network this year. All of the participating providers need to, when they sign their contract, they're also agreeing to meet these accountabilities. So these accountabilities include six different areas, the first one being technology. Participants are expected to implement and utilize an electronic health record that's compatible with CMD 2015 certification standards on or before January 1st, 2025. About 10 TINs that have historically participated in OneCare do not or may not meet the cert requirements. When we asked OneCare about this, they had established that about four do not have EHRs at all, and that six they hadn't received a response back from. They are not providing any financial support for these practices to upgrade their technology. The second one is care model, maintain alignment with OneCare's care model and actively pursue attaining 75th percentile or more in 50% or more of PHM quality metrics in 2024 and 85th percentile and 75% or more in 2025. The third one, health equity incorporates social determinants of health screening into yearly patient visits. Beginning July 1st, 2024 electronically report those SDOH screening rates to OneCare and develop a plan to collaborate to systemically address gaps in care by July 1st, 2024. The fourth one, engagement participate in 50% or more of OneCare's value-based care related meetings annually. Citizenship commit to OneCare's organizational values which include collaboration, excellence, innovation, equity and communication. And finally, cost and quality performance perform at or above the OneCare target performance level on follow-up after emergency department visits for individuals with high risk, multiple chronic conditions. I think I may have skipped. All right, I may be missing the slide, I apologize. Targeting down. So would you mind going back to 25 and walking us through the bottom of that slide? Sure, absolutely. So the bottom of this slide is the operating expenses per attributed life. You can see the beginning as attribution was much lower. It's to be expected that getting something up and running that your operating expenses are gonna be higher before you have all of your attributed lives on board. It went down during 2020, 2021, 2022 as attribution was increasing. And then with the loss of the Blue Cross Blue Shield payer program, you can see quite a drop in attribution between 2022 and 2023. It really changed that ratio. So we went from $61 per attributed life up to 75 per attributed life. And then in 2024, again, we see another drop in attribution and that is due to the Medicaid redeterminations. So that is why that in addition to increased operating expenses, why that dollar amount is higher down in that bottom, right? Thank you. Sure. And it does seem that I'm missing a slide, but I had mentioned that another way that one can increase their provider accountability was to change the ratio of their PHM payments to increase the bonus payments that the provider can earn by performing higher in their PHM measures. So overall, the potential payments to providers increased from 23 to 24, but the base payment actually decreased. So just practicing status quo, just reporting on care coordination, providers would actually earn less in 2024. But if they really work hard to shake things up and improve outcomes, they are eligible for a higher payment than they earned last year. Okay, target nine, this is the last target. This is regarding the March 2023 Medicare benchmarking report. We asked that one where one care ranks below the 10th percentile of among national ACO cohort or metrics where the trend has shown a decrease in performance between the years of 2019 and 2021, choose three metrics that the ACO will address through the quality valuation and improvement plan. The ACO should use metrics on which the ACO's provider network has the most influence on the outcomes and should justify their choice of said metrics. This target has been met, they chose three targets, ED utilization, annual wellness visits, and the number of beneficiaries with a primary care visit. And just to be clear, these are for Medicare beneficiaries. Here are just some snippets of one care's performance in these three different areas. One care is the dotted line there. For ED visits, you can see that they are, it looks like they're above, but you want it lower in this particular instance. So they are not even at the 10th percentile, so there's a lot of room for improvement there. The percent of members with an annual wellness visit, they are pretty close to the 10th percentile. Again, a lot of room for improvement. And then percent of members with a primary care visit, one care is coming in below the 10th percentile. So they are incentivizing their network to improve these metrics through a few different ways. They are using the PHM measures so that providers, in order to get that bonus payment, they have to perform well on these measures. So potentially avoidable ED visits and wellness visits for folks who are 40 years and older. And then also we saw, with networked accountabilities, there was one around their performance on ED utilization among folks with chronic conditions. They also, their performance incentive pool, which is another way for HSAs to be rewarded for high performance, those dollars are doled out to HSAs that have lower ED utilization. Okay, so those are the targets, what was met, what wasn't met. Now we're gonna look at some of their finances and their performance. So this is a very high level overview. I just wanted to review that we can look at the budget in two different ways. The full accountability or total cost of care budget is in the purple and then the entity level or organizational level budget is in orange. So the full accountability budget submitted is the result of provider network participation, negotiated payer program terms and one care strategies to develop their network payer programs. It includes healthcare spending for one care attributed lives for total cost of care services that are processed externally to one care. So that's 96%. So it's all the dollars flowing through one care to provide care. It also includes a small amount of population health expenses, just 2.5% and then administrative expenses at 1.5%. So the full accountability budget is reviewed and approved by the one care board of managers, but one care cannot unilaterally decide the contract terms of payers, such as payment models, benchmark trend rates and risk arrangements. The entity level submitted is developed at the discretion of the one care governance and leadership, meaning that it is elements of the budget that are not contractually obligated and are developed through committees made up of the provider network supported by one care staff and leadership and approved by their board of managers. Revenues that are not contractually obligated with payers include participation fees from the hospitals, fixed payment allocations, which also come from the hospitals and shared savings distribution, which is set in policy by one care. Expenses include the PHM investments, administrative expenses and shared losses, if there are any. If you won't see shared savings and losses in their budget because one care budgets as break even, meaning that they budget to hit their targets exactly, including the advanced shared savings dollars that fund the blueprint. All right, here is a view of their summary income statement. There is a lot here. So I wanna point out what years we're looking at with this view. We have 2018 actuals, we have 2023 projected and we have the 2024 budget. To the right of that, we have the delta between 2023 and 2024, and then we also have a delta between 2018 and 2024. So we can really see long-term how specific line items have changed. All right, so oops, I apologize. Okay, so I would ask the board to look at the subtotal of operating expenses, which is about two thirds of the way down. In 2018, you can see that it was at $13.7 million and then for 2024, it's up at 14.29 million dollars, which is an increase of about 4% over time. And then let's look at specifically what makes up those operating expenses. So for salaries and benefits, we have in 2018, it was at $7.3 million and then for 2024, we're up to 8.1 million. That is an 11.5% increase over time regarding contracted and purchased services. That line item has jumped a lot. It's jumped from 1.7 million up to over 4 million, which is an increase of 147.7 million. Some of that story can be told if you look at the software line, the software line has decreased considerably over time and that's due to the transition to Arcadia where they are now contracting with UVM Health Network to provide those services for them. So just overall wanted to point out that how those specific line items have changed over time. And then this slide just shows that the state has invested some money over time, especially in the earlier years, to get the ACO off the ground. One care had told us that in 2022, the loss of this funding was significant for them. Sometimes these monies also involved a federal match. So they were receiving quite a bit of support earlier on in their program from both the state and federal governments. Okay, so we're gonna pivot to performance review. So how do we measure success of one care and what data do we have to measure success? There are four different data points that we look at. We look at the quality and financial results, those annual payer contract scorecards. We heard about 22 performance last week. We look at the Medicare benchmarking report that one care is now submitting to the board twice a year. We look at one care's performance of their own PHM measures as well as their performance on their key performance indicators. So, and I just wanna say that even for the highest performing ACO, we would expect to see mixed results, areas of high and low performance, but these measures will help guide our focus as regulators and should similarly focus one care as well. So this is, we're looking at payer program results, their quality results from 2018 through 2022. Like I said, 2022 were presented, the results were presented to the board last Wednesday, November 29th. So we have five data points now. Comparability can be a challenge given several factors, difference in Medicare program quality framework in 2018 was much different than what it is now. The introduction of Medicaid expanded attribution, the public health emergency, you also should consider scale growth in each payer program over time and potential impacts on results. But the numbers I think speak for themselves at face value, it seems pretty simple, but there's definitely, it's a nuanced thing. The next is the financial results. This slide might be a little confusing. The numbers in parentheses are savings. They're in parentheses because they are under the target. So in this case, the numbers in parentheses denote shared savings. So we have 28, 3 through 2023 projected. And we, and then over on the right, we have the same table, but we took out 2020 because that was a very unique year with the public health emergency and people weren't able to access the care that they usually would. So you can see that Medicare is a clear winner in the story, year over year, Vermont comes in under the Medicare target, which seems great, right? So there's a couple of points that I just wanna make. This can't be, there are multi, there are multiple factors that should be considered as to what we come in under the Medicare benchmark. Part of it could be one care, but there are other factors. There are factors like the blueprint, the target itself is a negotiated number. So sometimes, if you're able to negotiate a favorable number, that makes it easier. The other thing I think about when I look at the savings in Medicare is the fact that the risk corridors are so small that we're really leaving a lot of money on the table. If those risk corridors had been larger over time, we would have been able to take home a lot more of those savings. We can also think about the sources of participation fees that the hospitals pay into one care, which is really the primary source of how one care keeps its doors open. It's through these hospital participation fees. We hear from hospitals that they are not able to break even with Medicare and Medicaid payments. So it's really the commercial payments that are keeping these hospitals going and must be ultimately paying these participation fees. So when there are Medicare savings, only a portion of that savings is actually paid out to the ACO network because of the risk arrangement, as I said, so Medicare gets to keep the rest of those savings. And if the ACO is saving Medicare money, but at the expense of commercial funds and the Vermonters who pay for those commercial, very high premiums and deductibles, it's just something to consider about the system. I think it's possible to frame it as commercial payers and Vermonters who are paying for those as kind of subsidizing this program and success, the success we're seeing in the Medicare program as well. The other thing I want to look at was the benchmarking report. This is a subset of measures that we look at that we have been advised that ACOs have particular control over. They include ambulatory care sensitive admissions. It includes total cost of care, emergency room visits and primary care utilization. So this shows performance of one care between 2019 and 2022. There's a handful of these that are inverse. I'll just throw that out there. And I think it's not a full picture because we don't have a national cohort on the slide to compare trends with. So it could be a national trend and not necessarily just a one care in a vacuum performance. But this, I wanted to show this for general, you can see the trend lines on the right and generally see kind of a mixed bag of outcomes. And you can see, especially primary care here as kind of appears down at the bottom. And those have just been declining since 2019. So as far as the PHM measure and KPI performance, there's a lot of overlap with these metrics for one care. So I put them all in the same slide. So I have the measures, I have the 2023, target that they have set for their network. They provided the progress of their network through March 2023. So just really Q1 performance on these metrics and whether their target, their self-imposed target has been met by their network during Q1. So for child and adolescent well care visits, the target is 57.5 and right now network wide, or I should say back then earlier in the year, they were at 57.2, but 40% of their practices were meeting that target. Developmental screening, the target is 57.4%. Network wide, they're at 60.4% and 40% of practices were meeting that target. So that target was being met at that time. For diabetes A1C poor control, the target is 39.9%. When they submitted 97% of practices were meeting this target and they said it was to be determined, but things look bright to the point that one care is removing this metric from their 2024 PHM measures because they feel as though the network has made a lot of progress in this area. And they've kind of topped out with their performance. Regarding initial hypertension, this is an HSA specific metric. There's no set number. They're expecting an HSA to look at their score and then improve by 10%. So if your HSA was at 40%, let's say it's expected that you would go to 44%. In the first quarter, one of 14 HSAs were meeting that target. For routine hypertension, again, a 10% improvement, first quarter of five of the 14 HSAs were meeting that target. Annual wellness visits, 40 plus. In the first quarter, 19% of practices were meeting the target, but at the HSA level, none of them were meeting that target yet. And then the final one is not a PHM measure, it is just a KPI, which is a potentially avoidable ED visits. And they were looking again for 10% improvement by HSA and 33% were making that improvement so far. All right. I wanted to also touch on one care support for primary care, as this is a consideration and statute that the board must examine as part of reviewing their budget of an ACO. Overall, the funding through population health efforts per attributed life has increased since 2022. Because this, and so you can see that here in this middle row, per life, it has increased per life. I'm sorry, the ratio has increased over time. So in 2022, for every attributed life, there was $71 of population health. And I just wanna note what this number includes and doesn't include, because as I mentioned, population health payments can be looked at in a few different ways, but in this analysis, it doesn't include FPP or fee for service. So I just wanted to note that. So the ratios have increased over time, but these dollars are linked to attribution. So between 2022 and 2024, we've seen quite a drop in attribution. So the total amount going to primary care has dropped from 16.1 million down to 12.7 million. And I think it's easy to say that, more per life is going, and when these dollars are linked to attribution, it's like they're doing all they can to support these primary care physicians or programs. Given the number of attributed lives they have, I think the one point I'll make is that these practices are still seeing the same patients. It's just fewer of them are attributed to one care. So they are still providing the same care for patients. They're just not receiving as many support payments to care for these patients and to innovate and to hire additional staff. So I think this shows that tying these dollars to attribution is challenging for the practices as attribution has shrunk. Okay, so these are the options for budget modification and approval. I will read through each one and then we'll move on, but we can always come back to this slide. So the first one is to fund one care's budget as submitted with any or all reporting conditions as outlined in the following slides, which we will review. Number two is the same as number one, plus a new condition that one care must hold the Medicare advanced shared savings dollars as risk at the entity level unless they increase the Medicare risk corridor for FY24. Third option, reduce one care's salary and purchase services from 12.5 million to the 2018 level of 7.4 million. And evenly reallocate these funds to non-hospital owned independent primary practices to improve primary care, including the additional conditions regarding reporting with or without that risk option. Fourth option, reduce one care's administrative expenses from 14.3 million to the 2018 level of 13.7 million and evenly reallocate these funds to non-hospital owned independent primary care practices to improve primary care, including additional conditions regarding reporting with or without risk options. Number five, reduce one care's administrative expenses from 14.3 million to 11.6 million in order to maintain the ratio of administrative expenses to attributed lives at the 2023 level of $75 per life. You could also add the additional conditions, the reporting conditions with or without the risk option as well for that one. And the final one is one of the HCA's recommendations. Reduce one care's purchase services line by 50%, which is currently at 4.3 million, and evenly reallocate these funds to hospital owned independent primary care practices to improve primary care. And then you could add additional conditions regarding reporting with or without the risk option I described in number two. That's a lot to think about. I will come back to the slide. I wanna walk you through the reporting conditions to consider. So these conditions are consistent with previous years. One care would notify the board of any material changes to their budget and explain any variants. Submit a revised budget by March 31st, 2024 and present on the revised budget in April 2024, including final payer contracts, attribution by payer, a revised budget, hospital dues and risk, and changes to the risk model source of funds of population health programs. Third, notify the board of any use of reserves or line of credit or any adjustment to participation fees. Implement benchmark trend rates for payer contracts and alignment with the board's decision on the Medicare ACO benchmark. Our presentation on that is next week and the vote the following week, the GMCB's Medicaid advisory rate case and for commercial contracts in alignment with the ACO attributed population and the Green Mountain Care Board's approved rate filings. Fourth, the last one here, engage in payer programs that qualify for APM scale to the greatest extent possible and align payer programs in key areas to the extent reasonable, explain non-scale qualifying programs and areas of misalignment require continued reporting on payer programs. These are also consistent with previous years, fund population health management, management and payment reform programs as detailed in the FY24 submission or we may end up modifying possibly and notify GMCB of any changes, including funding shortfalls, changes in program scope or an and an analysis for each program line item as to whether and why the funding is appropriately scaled by attribution or some other factor. Report evaluation results and evaluation focus areas for 2024 to the board, fund the support and services at home or SASH program and the blueprint for health payments to primary care practices and community health teams consistent with the amount approved by the Green Mountain Care Board in the Medicare ACO benchmark process, which will be presented next week. These deliverables are pretty consistent, but I would like to perhaps update some of the, the conditions are consistent. I would like to update some of the deliverables, work with the Medicare Advantage plans working in Vermont with a particular focus on Vermont based programs, offered by Blue Cross Blue Shield and the UVMMC MVP program to develop scale qualifying programs, report FPP data and progress towards the goals as specified in the ACO reporting manual and 24 guidance report on their CPR program and make it some improvements to the benchmarking report, including a statistical significance analysis and a report on risk of all cohorts for each year. And then I included the new one that I mentioned in option number two, one care to hold all, hold risk for all Medicare advanced shared savings dollars unless the Medicare risk corridor is increased above 3%. Just a quick timeline seeing, there's a lot to think about, but we have two weeks before the potential vote and the potential for to deliberate next Wednesday. That is all I have at this point. I will turn it back to you, Chair Foster for any board discussion. Great, thank you, Ms. Sawyer. And just to be clear of the options that are presented in the potential conditions, the board can of course consider others as well. That's just a set for us to start thinking about in advance of the deliberations. Absolutely. I'll open up to any board member questions or comments. Michelle, I had a question on something that you said related to the financial analysis. I thought I heard you say, and I either you misspoke or I missheard that Medicare benchmark was negotiated, which is not the case. The board sets the trend for the Medicare benchmark based on data that is provided by Lewin, which is Medicare's contractor. So I just wanted to circle back to that because I didn't, I don't know if I heard you wrong, but that would be incorrect if that's what you said. What you just said is my understanding as well. I apologize if I misspoke. That's okay. I thought it was in relationship to whether or not the benchmark was on, was like a reasonable target. So since we said it- That's just for the commercial. The commercial ones were negotiated, right? Right, that's true. Okay, thanks. Yeah, and there was some indication in the MVP discussion last week about their benchmark, not the risk adjustment in their benchmark, not adequately adjusting for actual risk. So that makes sense to me. Thank you for that clarification. I do have questions on the, could we go back to the recommendations? I guess I'll start there. So why are we picking 2018 in these specific numbers in three through five? That is a good question, Robin. This is what I heard as interest, these specific options. So I tried my best to deliver a series of options that fell in line with what I had heard was of interest to the board. Okay, so maybe before we negotiate the board members who had interest could articulate the why these years and why these numbers so that I can understand where it's coming from. I mean, obviously people can choose to do that today or not, but that's, it's, I'm not seeing like the connections here. And I'll just tell you my other questions. So why independent PCPs, which are 18 practices as opposed to putting more money into other population health programs, which understandably would make it more diffuse but would potentially have more impact on moving. If this is connected, for example, to a quality, a particular quality metric or something like that, I'm not sure if 18 practices have enough attribution to move the ACO-wide performance measure. So I just have a question about that in terms of, like I need somebody to connect the dots for me. Sure, I can say a couple of things. So there are 18 practices that are enrolled in the CPR program, but there are more, I believe there's 24 approximately independent primary care practices that are part of the one care network and just not all of them participate in the CPR. So that's one thing. The other, as I believe, this was noted this way because of the quality of independent primary care and their ability to see patients. But I think that this is, it would be a good place to discuss and I don't think it's a hard and fast thing. It's just a starting point for discussion. Could we get the evidence on the quality for these independent practices, these 24, so that we know that it matches whatever evidence you're referring to? So that's a question. Also, you had indicated on slide 38 that attribution is down, but that doesn't necessarily mean the primary care practice are seeing fewer patients. Do we have data on that? For example, we did hear in a public comment about a practice that had reduced their number of patients rather recently because of some staffing issues that they had. So how do we know that the practices are seeing the same number of patients? I can certainly see if I can find that data and provide that Robin. Okay, I mean, it's not that big a deal. I just wasn't sure where that statement was coming from given that we had had that public comment previously. On the attribution generally, do we have any information on the current status of the Medicaid redetermination and how that's going? I would, to your point earlier, a big decrease in the attributed lives is related to the Medicaid redeterminations. The stats that I had seen early on from the DEVA website indicated a lot of that was paperwork, which is not unexpected. That's typically why people fall off during redeterminations. So I was just curious how that was going. If we have any information on whether or not they would expect some rebound. So for example, since Medicaid will pay retro 90 days, if somebody shows up at a hospital and the hospital is able to get them signed up again, so they can get paid for that day, that will help with bringing people back onto Medicaid. So just getting any sense of that might be a little helpful if we're going to be looking at her life targets. Sure, we can reach out to DEVA between that and the attribution reporting that we receive from OneCare on a quarterly basis. I can try to get a clear picture of what is happening currently. Thank you, that would just, that background would be helpful. And then on the Medicare shared savings at risk at the entity level, why the connection to increasing the risk quarter? Like, from my mind, let me just give you, so in my mind, the reason why we had suggested, at least my reason for why I had voted for the Medicare shared saving dollars being at risk at OneCare was because of solving the issue that we've heard from hospitals that they were perceiving the advanced shared savings as asymmetric risk. So that then I don't, I can't follow that through to increasing the risk quarter and how that would solve that problem, which is what I thought, at least for me, was the problem I was trying to solve with that. Now, I will say, you know, I am of two minds on the risk at the OneCare level. There's a lot of unknowns obviously about where we will be moving forward in the future. And if, and this is a big if, the state were to pursue and sign an agreement in the ahead model, the risk in that model is on the hospitals. So there's an argument that in, and obviously we don't know if we're gonna do that or not. So this is, this argument can go either way, but that if you wanted to prepare folks or you wanted people to be more prepared for holding risk, you would actually shift it onto the hospitals now. So they get some experience of that over the next two years, should we move forward with that? Obviously there's a lot of ifs there, but so that's just some initial thoughts on how I'm thinking about that and would love some discussion around that. I'm gonna be quiet now and look at my notes and see if I had anything else and give other folks a chance to speak. I can hop in for a couple of questions. Can I just follow up with just a question coming from Robin's question. Could you provide argument, Michelle, for we sort of had the argument for why we're more at the hospital level may have some advantages for potential future. We'll watch it. Chris Newman, can you find the argument for why? How do you think they're all at risk? I'm having a hard time hearing you, Dr. Merman. Oh. Same. Let me pass and then come up with a different solution. Michelle, can I add just a quick question? And this is actually a little bit following on some of the, if some of these recommendations are looking at a per life level, per attributed life level. Just one other question I had and maybe this I have to go back to our slides originally. I'm trying to be helpful to unpacked how much of the decline in attributed lives is also related to Medicare Advantage uptake. So I'm just kind of curious if we have those numbers as well. I know most of it is Blue Cross Blue Shield and the redeterminations, but if there is that data, that would be helpful to know. And I'm just, I guess I would say that I'm looking at these now and it would be really helpful. I think this is on the agenda for next week is to revisit, have some deliberations and revisit and it would be really helpful for me to see pros and cons associated with each of these options and some assessment of intended and potentially unintended consequences of some of these. And so if we can just have a little bit more context for the justifications, what we're hoping to achieve and some of the downside risk of some of these proposed modifications would be helpful to me. And I'm gonna obviously think about these for the next week. I may have some other ideas and I'll bring them up next week if I have them. So, but I appreciate all the work that's gone into this. Could I give another try? Sure. Okay, how's that? Are we, we have audio? It's better, it's much better. Sorry about that. I have a, my old computer died. I have a new computer and this is the made in voyage here and seems like I got some kinks to work out. So my question for you was that Robin talked about the potential advantages of having risk held at the hospital level. And I was wondering if you could just refresh me on the sort of the logic behind having that risk held at the ACO level and what the board was trying to accomplish by doing that last year and potentially in the future. Sure. As Robin said, a lot of the, we were hearing from hospitals that including those advanced shared savings dollars as downside risk, it really made the Medicare risk quarter appear to be asymmetrical. So the hospitals had to earn back those dollars before they could even really start looking at savings. There was more at loss than there really was. It set them behind in saving money. And I would say nationwide, it's pretty common to see ACOs at the entity level hold at least some risk. And so we thought that transitioning those dollars to the entity would both solve the asymmetrical risk corridor problem that we were hearing existed and it would give one care some accountability as well. Okay. So more, your recollection of, or opinion on this would be more that it was for trying to alleviate that perceived risk by the hospitals with the advanced shared savings money more than sort of the concept of like a skin in the game where as an incentive to try to one care to try to figure out how to save, have more shared savings. There was, I think both of them played a factor, but I would say the former was the larger concern. Okay. And I do wanna thank you by the way, just upfront for like the tireless work that you've put into preparing and learning and presenting and I really appreciate the hard work of the team and a few specifically. So I just had a few other questions. I think some of this will take a little bit of time to digest of what you presented, but have we received any information from one care about the request for trying to figure out the administrative cost by program? So what the various programs cost? No, we had asked in the budget guidance for one care to provide that information their budget broken out by program, but they said that it's not how they do their budgets. So they were unable to be responsive to that request. And then have you received, I hadn't seen, but have you received any information or had any other communications for one care regarding the variable compensation, specific and measurable goals that are in the care board's rule for the next year or if we know how those are gonna shake out for this budget? No, from my recollection, the corporate goals to which their variable executive compensation will be tied will either be determined by their board of managers later this month or potentially in January after the vote. Okay. I think that's all I have for now. Thank you so much. Hey, Michelle, it's Tom. I just wanna also share my thanks for all the work. It's tremendously big lift. And I just have a couple of questions. One, and I'm not sure they can be answered today. So I'm not expecting, not trying to put anybody on the spot or require anything, but could we go to slide 25, please? So I'd like some help understanding how the numbers shown here compared to the HCA public comment. In the public comment, they had in their appendices, there were figures that showed declining public health payments over time and increasing, I think they said, payroll and consulting expenses, which I think would be in rolled into operating expenses. These numbers seem, I'm having a hard time squaring these numbers. These numbers look like things are moving in a better direction for the from a one care perspective and the HCA public comment didn't look as favorable for one care. And so I need some help, maybe from you and staff and from the HCA to try to square these, at least in my mind, because I'm a little bit confused. And we can do it now, we can do it during the week, we can do it next week during deliberations, but I just had some trouble lining these things up. If there's an easy answer, I'd love to hear it now, but if we need to wait, can do that. I can offer a brief explanation in that I believe what the HCA is considering population health spending is different from what we had traditionally presented. This table we've shown in previous presentations and we felt it was important to keep it consistent. So in this particular slide, those dollars include Medicare advanced shared savings dollars. So that could be the difference between what the HCA is showing and what we're showing with this slide, but that's just off the top of my head, the first thing that I would flag, but we can, I think have a good conversation about this and with the HCA. Great, I see Dr. Schulteis is here too. So happy to hear from him now or at any time, but just trying to help me square these, that would be great. Do you want me to answer, Tom? Like I have some rough things. I mean, I'm just thinking about other things that may be going on. I think Michelle is right about the methodology. If you look at a, well, I tried, perhaps unsuccessfully in that there's a paragraph in that section where I go over how it's done. Looking at this, I think because of confidentiality concerns, we went with the budgeted numbers each year. We also excluded 18 because we felt it was, well, I felt it was unfair because of startup costs. So I mean, that's kind of like a judgment call, right? Like whether we include 17 and 18 or just 18 or neither. And then I'm looking at this and I think part of the reason and in terms of how their admin costs look, it looked better, but PHM didn't look bad, makes it look worse is we put it in real dollars. And I think that's a general preference that I have for comparing financial numbers over time. So that's gonna inflate the 2019 spend relative to the 2014 spend. And then of course, as Michelle pointed out, it's what we're counting as PHM spend. So whether we're counting the blueprint, whether we're counting FPP, I think I tried to do it similar to the PHM spend in the North report, which I wasn't able to perfectly replicate. It was a little unclear what data sources they were using. And then I also, with the caveat that I also excluded blueprint spend. So I guess all in all, I think it's just, it's just different looks. I don't think, I wouldn't expect numbers to line up exactly because we're using relatively substantial different methods. Okay, so just a couple of follow-ups. If I could, when you say real dollars, should I take that to mean inflation adjusted to current day? It's adjusted with CPIU nationally for 2023. It's using the average of the existing nine months of CPIU as I guess estimated. And then for 2024, it's using, well, at the time that I did this, the new economists approach, the state economists had it released CPIU projection. So it was using a CPIU assumption for 2024 based on I think two years average. I spell it out in one of the footnotes. So definitely take a look at that. I have this bizarre love for footnotes. So it's in there somewhere. I appreciate it. So there is basically trying to get it all to a current dollar amount, best we can. And the rationale for leaving out the blueprint, I could imagine, correct me because I can also be wrong about these things, but leaving out the blueprint is to try to isolate the effect of one gear. I think that's true. I mean, I think a plausible argument could be made that you should include blueprint because of how the paths through structure works and the reason we have one care. I think from my perspective, I felt like it was important to try to isolate what one care is doing that's new and not just what the blueprint is already doing. I think you probably could make the argument that but for one care, there would be no blueprint. But that was a choice. I appreciate your transparency with all that. Yeah, I think it'd be, this has been really helpful, but I think they're not just small differences. Sometimes the differences are directional. And so helping us all feel confident about how these things differ, I think would be good because they have implications for the options that were outlined. I think three, five and six would all depend on our, whether we, how deeply we understand this and the HCA analysis. Okay, could, there were hands that went up. I don't want to move on if other people want to participate. Tom, we'll take public comment at the end. Okay. I thought one of our staff, I thought Matt Sutter. Matt, did you have something? I saw your hand go up. I did, I was just going to explain the difference in how it works out and things that Eric hit, everything I was going to say. Okay, well, that's good. We can provide a crosswalk, kind of explain the differences this board next week. That'd be great, Matt. Thank you. Could we go to slide 36, please? And this one, I just, I wanted a little bit more time to look at. Personally, I don't have any trouble with inverse measures. I just have to slow down and remind myself of what is the trend we're looking for. Some of these, the ED cost of care, total inpatient cost, primary care, they're concerning. A lot of the trends are concerning in this. And I just, I will take some more time to look at it. It's not substantially different in my mind to what was presented last week regarding the quality performance. But this is a different way to look at it. And it's, they're concerned. So I wanna make sure that I'm understanding it. And finally, the next slide, please. Here, so in one case presentation earlier in the fall, I don't remember who from one care, but they had mentioned a desire to stop tracking the proportion of patients with poorly controlled diabetes. And I remember at the time that the rationale for that was that their performance had topped out. It'd been the same year over year. And it gave me the impression during the meeting that that must be, they must be doing really well. And this surprised me because in the prior look at the proportion of patients with an A1C level greater than nine, the numbers hadn't been good. And here, diabetes, A1C poor control, 39.9%. Correct me if I'm wrong. That means nearly 40% of patients with diabetes are poorly controlled. There's nowhere that that's a good performance. And 97% of practices meeting it isn't good performance. So I don't know if I'm reading it right, but that jumped out. Yeah. Forgive me, and I'm going off of my memory right now, but the memory that I have from the prior presentation was those rates were in the 21, 22, and there was one year where it dropped to 11.4, but it was kind of mostly around the 20 to 23%. So I'm not sure if these are looking at that in a different way. It's probably, I'll stop there, but there were different numbers in that presentation that don't meet these. And so I wonder if we're just kind of, if it's just being looked at differently. Sure, 20% is not a good number either, but I'd like to understand, this isn't financial question, this is more of a performance question, but those numbers are concerning. And so I'd like to make sure that I understand that. Because if it's 20, 30, 40%, that measure should not be sunsetted. These are the patients who, patients with poorly controlled diabetes, with comorbid mood disorders, anxiety and depression, are the group that commonly have the most unplanned ED visits and inpatient admissions, and then surgical admissions. As first one, the big toe is removed and their foot is removed and their lower leg is removed. So these are the patients that most ACOs are really trying to find the patients with rising risk in order to prevent those ED visits and admissions. So if the numbers are in the 20 to 40% range, they should not be sunsetted. Then there's two more things. The ACO level risk that Dave and Robin were talking about, ACOs are commonly doing that. They're accepting oftentimes 100% of the risk. And the reason that we were talking last year about this ACO having some risk is that providers were telling us that they did not have the data in order to know what to do better in order to earn their shared savings and that there were no programs from the ACO to help them address the care coordination, communication needs in order to improve care. So the providers were saying, we're not getting value from the ACO that would allow us to take more risk. So by shifting some risk onto the ACO, we were trying to say, give them more analytics, give them more programming that would help them better manage their patients because that's what ACOs are supposed to do. The ACO concept was providers should be sharing risk, not just payers, not just the Medicare Medicaid programs, but providers should share risk also. In this particular case, there's in my mind justification for the ACO sharing some risk to improve its performance to help enable the providers to meet what they need to meet. And then with the modification options, these are not mutually exclusive, right? Like somebody could get all crazy and say, I want two, three, and four. And some new combinations possible. And I don't remember exactly why the in last year's budget presentation, we were trying to determine what costs one care had that were fixed and what were variable. What costs should fluctuate depending on the volume of patients, attributable lives and what you just need to run a shop. And I asked, when were you fully staffed to meet the fixed cost of running the shop? And the answer was 2018. That's all from me. I have just a couple of little comments and things to think about off of what some of the other board members said, one off of what member home said about sort of some of these options here and thinking about the pros and cons and other ways they can be thought of. I think over the next two weeks, we should work on that and see if there are other options we want or other ways to use the money. And if there's any things that we need to add to it to make sure it works effectively. So, for example, with the population health money that went back to the hospitals, we don't have any real certainty or evidence at this point that it was used for those purposes. And so if we're going to use money in a different way in this budget, prove it differently, we should think about how we need to make sure that money will be used effectively. And also to member homes as point or maybe as Robbins, where we're putting it and why we should think about quite a bit. The other thing I would think about kind of at a large level is it's one carers burden to justify their budget. And it looks to me like over the 2018 to 2022 results that we have, the quality is rather inconsistent, flat or even negative in some regards. Certainly not like a consistent trend line like we saw last week in the payer presentations we had. It didn't really look like it was defined or it could be really attributed to anything that one care was doing programmatically. And so if the results are sort of flat, how do we conceptualize that in light of their burden to justify their budget? And then the savings, I think that the point was well made that it could be based on targets, it could be based on performance, it could be based on noise in the data, it could be based on other healthcare reform efforts, it could be based on demographics, any number of things. And so it looks to me like from the slides and the evidence that we received from one care that the savings, and I'll quote savings, is also somewhat inconsistent from year to year and payer to payer. And certainly as to the two buckets we're most interested in, I think for Vermont payers, Medicaid and commercial is not significant. And so thinking about those, how are we conceptualizing whether one care met its burden to justify its budget? Similarly with the administrative costs, I'm trying to think of what are we getting for these things? And this is a point I raised last year. Why are we putting, or why is one care putting certain amounts of dollars into some programs and other amounts into others? And is that the right mixture? I think at the time there wasn't really a clear answer on that. But if we don't have a data that I think the staff had asked for, Dr. Merman, about the administrative cost by program, I struggle with saying, okay, well the whole budget and whole then is approved and they've met their burden, right? So if we don't know what programs are really working or having an impact to the positive for Vermont, I struggle with what the evidence is or justification is to satisfy the budget. And I guess I would say that in all candor I'm a little bit vexed by the one care budgets. And I say that because there are some things in this year's budget that I liked quite a bit that I thought were better. I thought the shift in the amount of the base being a little bit lower and the bonus being higher was beneficial. I thought some of the approach was a little bit improved overall. But really it seems to me like the crux of the benefit of the one care program are some of the structural things, the money from the feds for blueprint and sash. And that's really just by mere existence rather than a programmatic effort. And then some of the waivers that's beneficial and some of the pass through and redistribution of money to where we want it, I think is beneficial. So I'm trying to think about what those cost and because I think those are justified because those are good. And then the other is it sort of unclear if they're beneficial and or whether or not the burden's been met on those. So I'll leave it at that. I don't think I had any other. Oh, one other, one question, Michelle for you. On the state support slide, could you go back to that real quick? I think it was informatics support. Yeah, thank you. These funds were they matched by the feds, did you say? I believe in some years they weren't, I would have or they were, I would have to get back to you with the details. I don't feel confident in saying definitively that they were matched every year. Okay. And can you remind me why they dropped off in 22? That may have been when the match expired. I don't want to say anything incorrect. It may be because the high tech funding dried up at the end of 2021. Okay, Robin's nodding. So the high tech program was a federal program to find fund advancements in health information technology and that program sunsetted at the end of 2021. And then these funds were not, these are not part of the admin or operating expenses of one care. They're additional revenue in the budget that we see. They are, yes, they would show up under the revenue. Not as admin expenses, right? Because they're right. No, because this is money coming in, yeah. Yeah. Okay, I had nothing else. Thank you very much to you and your team for this presentation today. It was a lot of work for sure. I'll turn to the healthcare advocate for any questions or comments they may have. Morning. Also thanks, Michelle, Russ and Angela for all your hard work on this. And thanks for a great discussion this morning to all the board members. I think our comments, concerns and recommendations are really well summarized. So thank you, Michelle. I think our concerns about relative declines in one care's PHM investments over time relative to some other expenses is a key concern to us. And to remember Walsh, thanks for your questions and thanks to Eric for answering in real time about that. I think in general, there are some pretty consistent trends between what the board staff presented and what we are analysis did. I think there can be some methodological differences, but I think it's reasonable to us to expect PHM to either at least at a minimum be consistent or increase over time. And that's not what we've seen at least in our analysis, which leads us to question the level of value that the model provides to Vermonters. And I wanna recognize that the board is in a tough position having played a role establishing one care, but we believe that the next all-payer model agreement should present the board with an opportunity to really conduct its own analysis to kind of what you were getting at Chair Foster around return on investment. I think the board needs to do an analysis for itself and really decide to decide about the future of one care and whether or not it makes sense to continue with the all-payer model or to consider alternative funding mechanisms. So thank you. And I'll turn it to public comment via the raise the hand function. Ms. Wasserman, good morning, how are you? I'm fine, thank you. I just have one quick question for the staff. One of the earlier slides, I don't have the number. Talked about fixed perspective payment. If we could go to that slide, I'd be interested in understanding a little more clearly why Medicare is considered fixed perspective payment when in fact fixed perspective payment is also known as a capitated payment. And my understanding is that those fixed perspective payments for Medicare on behalf of Medicare for the hospitals is reconciled at year's end. So my question is why is that considered, why are the Medicare payments considered fixed perspective payments? Great question. Sorry, can I try and jump in? Absolutely. So let me just ask the question that I think would be helpful, which is, is that correct that the Medicare fixed perspective payment is reconciled? That is correct. And are the others? Medicaid is not, is unreconciled. And can you explain the rationale for that and why we include it here? Well, the Medicare payments even though they are reconciled at the end of the year to fee for service, they are still fixed perspective payments made to the providers. So that payment mechanism still falls under the definition of what a fixed perspective payment would be. Medicare has not expressed an interest in being involved in an unreconciled version of this, whereas negotiations with diva have resulted in the ability for the network to receive unreconciled fixed perspective payments, which allows providers to, if they overspend, they spend more than their fixed payment was than they're on the hook for make somehow figuring out the difference. But if they spend less, then the fixed perspective payments they receive for the Medicaid lives, then they get to keep the additional monies themselves. Sir, does that answer your question? Yeah, so just for like a simple example, if I am a physician and I have a Medicare patient, let's say 10 Medicare patients through the course of the year, I get a capitated payment and that reconciliation is at year's end. Correct, that's my understanding. And if my billings on a fee-for-service basis are greater than the capitated payment that I receive from Medicare, what happens? The, you have to send that money back and you are losing that money, that's my understanding. Right, so my capitated payments are $100, my fee-for-service billings are $125. Right, you only get to keep what you spent for fee-for-service, or your, yes, if you spend more than what you were allotted, then you have to, now I'm getting confused, Owen. You know what, I put you on the spot. Let me, we can get back to this. I think we can just briefly address this when we have a little bit of time to make sure we check the regs and the rules and make sure we have it right, so. Yeah, I want to speak to it correctly. Yeah, yeah, that makes sense. Any other public comment? Yeah, I'd like to make a comment. I, my computer dropped out, so I didn't hear the discussion between Chair Foster and Michelle over the last couple of minutes, but I guess what I would like to see is that the Medicare line be titled Advanced Payments, because that's, in essence, what is occurring is that the hospitals get advanced Medicare payments that are reconciled to fee-for-service at year's end, and I think a more accurate description is Advanced Payments, as opposed to Fixed Perspective Payments. It takes the term Fixed Perspective Payments and dilutes it, which I don't think is helpful in this discussion. And again, I apologize for not being able to hear what you, what Michelle and Chair Foster were discussing, but I think calling things, what they are, actually helps clarify and reduces confusion, because let me say there's a tremendous amount of confusion in all of this whole endeavor. Thank you. Thank you for your comments. Any other public comment at this time? Mr. Berman, I've been asked in a number of hearings to remind folks if people are affiliated with any of the regulated entities. So I'll just introduce you, Mr. Berman, if you don't mind, as the CEO of OneCare. Thank you, Chair Foster. And thank you for the opportunity to discuss the important work that we're all doing together with the public. I think the current environment that we've all acknowledged is really challenging for healthcare providers and hospitals in Vermont. And I think we're working together to try to help them through this challenging period and deliver better value for remunters. Some of the comments we've heard about the quality measure performance, I think reflects the struggles that they're having. I think OneCare and the all-pair model are in place to try and help these providers and drive improved outcomes for remunters. We have to acknowledge that the world is very different between 2018 and 2023. And some of the measure decline performance you're seeing are the struggles that healthcare providers are having being understaffed and under-budgeted to do the work they need to do. Unfortunately, the efforts of the ACO can't stem all tides. We're trying to work with the providers to do this work. But should be remembered that the ACO really is the providers that are in the ACO. It's not a standalone entity as some other ACOs that are either affiliated with a for-profit entity or are trying to aggregate a tremendous volume of providers across the country together. These are Vermont providers coming together as part of the all-pair model to do this work. And I just want to be clear that the funding Vermont receives is not merely based on the existence of an ACO. The funds are part of the agreement because of the work that OneCare is doing and the measures that are in place. Yeah, I think the healthcare advocate certainly is well-intentioned and I appreciate their feedback. We want to do great work and we want to work with them to address their concerns. Unfortunately, the measures they're introducing and they want to hold accountable, OneCare accountable to don't really make sense to me. I'm trying hard to understand them and I listened very carefully when the gentleman from the healthcare advocate spoke. I don't know that they really mesh similar to what Member Walsh said with my understanding of what we're trying to do in the budget. It's really important when you look at ratios to consider what the relationship between the numerator and denominator is and how you've gotten to those numbers and whether that's truly an indicator of what you're trying to measure. So just to be clear, I don't agree with those ratios. I think as Member Walsh pointed out, page 25 of the presentation reflects the reality that I know is in our budget. And I think it's really important also to think about correlation and causation just because you can draw a comparison doesn't necessarily mean that one thing caused the other. It's a difficult situation in Vermont. I think we all acknowledge that. I think we've got a good plan in our budget we want to achieve on and measure ourselves on and have you measure us on as to whether we can do that good work and achieve improvements that are quantifiable in 2024. So just to sum up, I think we've presented a reasonable and balanced budget that's gonna allow us to support the goals of the all-payer model and help our participant network provide value to Vermonters in the coming year. It sustains the funding for the core population health management programs that we have like CPR and the mental health screening. It also helps expand the use of waivers that cut through red tape for providers. And it puts more emphasis on quality measure and total cost of care performance than it has in prior years. As always, our team's gonna work really hard to align incentives around the quintupling and break down barriers for providers as they seek to collaborate and innovate. And I just wanna close by saying one care's operating budget and our population health management investments comply with the degree amount of care board standards. This is very intentional. We take what the board says seriously and we try to incorporate a lot of the recommendations that we've heard over the past 12 months into that budget. And I think it really reflects those efforts. You know, when I read some of the recommended alternatives I do take great pause. We put a lot of thought into how that budget is constructed. And if you evaluate it, I hope you take that into account and think about as Member Lunge stated what the ramifications of radical changes to that budget might be. So thank you for your time. Thank you very much for your comment, Mr. Vermin. Any other public comment at this time? Why don't we take a 15 minute break? We'll come back at 11.05 and we'll move on to the Medicare only ACOs at 11.05. Thank you. Okay, good afternoon. It looks like we have everyone. So we'll resume the green amount of care boards hearing of December 6th and we'll turn to the Medicare only ACOs and Ms. Sawyer for the presentation. Great, thank you, Chair Foster. I am joined today by our staff attorney, Russ McCracken to present a few slides as well. The agenda for this afternoon, just touch briefly on the scope of review and then we'll look at Lore Health's budget. We'll review the public comment that we have received, staff recommendations and the potential motion language. And then we'll go right into a review of Vitalize Health 9. We have received some additional information that we want to review with you all. We wanna touch on the public comment. We'll review some staff recommendations and there will be time for board discussion, potential motion language and of course, at the end, we welcome public comment. So the scope for Medicare only ACO reviews, they are not subject to certification in Vermont. Smaller ACOs are under a different section of the statute. Lore Health and Vitalize Health 9 have less than 10,000 lives in Vermont. And in previous presentations, we've gone more in-depth into what the statute says. So this is just a brief reminder. Both of these ACOs are participating in standard Medicare models with terms that are established under federal rule. And both of these ACOs are multi-state ACOs. So we will start with Lore Health and their FY24 budget. So to date, a single public comment has been received and it is from the Office of the Healthcare Advocate. They wanted to share some of their concerns. They include lack of evidence regarding the efficacy of the model of care, a lack of transparency and their profit priority motive. Recommendations from the Office of the Healthcare Advocate include that the board require Lore to submit financial and quality reporting to the board annually for the board to establish a deadline for confidentiality requests in the budget guidance and that the board should expand the scope of authority over Medicare-only ACOs. So here are some updated staff recommendations. These are very similar to the ones that we reviewed previously. The text in red is just some updated language, tightening some things up, but the intent remains the same behind these recommendations all in all. So I'll talk through them. Recommendation number one, Lore Health provides to the Green Mountain Care Board its shared savings and losses segmented for Vermont. This is a carryover from FY23. Recommendation number two, Lore Health provides an updated version of their Vermont financial summary. The GMCB staff would develop that template and set a deadline. Recommendation number three, Lore Health provides to the Green Mountain Care Board its Medicare shared savings program quality reporting segmented for Vermont if possible with appropriate restrictions to protect patient confidentiality. Recommendation number four, following three performance years in Vermont, Lore Health provides reporting for those years on GMCB specified metrics which may include the categories of inpatient medical, inpatient surgical, emergency department, professional office visits, ambulatory care sensitive admissions and any additional metrics. The GMCB staff would develop the template and metrics and set a deadline. Recommendation number five, Lore Health provides a semi-annual update about how Lore Health's care model is working in Vermont including any consumer complaints received from attributed Vermont beneficiaries. The board staff would develop this template. And the final recommendation is that a representative from Lore Health must engage in an orientation led by the blueprint for health within the first quarter of 2024. And just a note on that final recommendation there had been a question during the last time this topic came before the board about the availability of these orientations from the blueprint for health. And I did touch base with them and they are happy to engage with any ACO that would like an orientation on their program. So the suggested motion language for Lore is here. Move that the GMCB approve Lore Health's ACOs FY24 budget as submitted to the board subject to the conditions reviewed by the board today. So we're gonna scoot right along into Vitalize Health 9 ACO. We have received as of December 5th at noon which was yesterday at noon 58 public comments. The public comment period ran from November 1st through December 5th at noon. We did extend that public comment period for several additional days following feedback from the public that they wanted more time to have their voices heard. So the board welcomes these comments. We encourage the public to engage in its processes. And so here are some of the themes that we heard. There is concern around the private equity firms and for profit motive. The concerns around privatization of Medicare, concerns surrounding potential effects on healthcare delivery. There was as I mentioned a concern that the public comment period was too short and some public comments around how the board should reject Vitalize budget or delay the vote. Little Rivers FQHC, which is one of the participating providers in Vitalize's network, did submit public comment. They said that they wish to engage with value-based care arrangements and did explore several ACOs. The ACO agreement does allow for disengagement with the ACO at any time. And that they have signed up to be a part of Vitalize Health as a way to ensure their financial health of their practice. The office of the healthcare advocate also submitted public comment. They voiced concerns about the motives of private equity firms or for profit. They are skeptical that Medicare-only ACOs, whether they create savings or reduced spending, they're concerned about the efficacy of the model of care and they're concerned about the Vitalize potentially being a competitor to OneCare Vermont. They gave the board a set of recommendations that Vitalize Health9 to submit financial and quality reporting to the Green Mountain Care Board annually, establish deadlines for confidentiality requests and budget guidance and that the Green Mountain Care Board should expand the scope of authority over Medicare-only ACOs. I wanted to just review a little bit of new information that we've received from Vitalize since we spoke about them last. They had some follow-up items that they were going to provide for us, one of them being a chart, an organizational chart. So all the ACOs on the chart are owned and full by Vitalize Health LLC, except for physician leaders, which is an ACO, which Vitalize Health has an investment and operate under a management services agreement, but you can see that they have Vitalize Health9 as well as several other ACOs under different federal models. An update regarding their health equity plan. During the hearing, it was stated that Vitalize Health9's health equity plan would roll out nationwide in 2024. The ACO provided an update stating that while CMS has approved the plan, in the start of 2024, the initiative will actually be implemented in a single zip code in Mississippi and not nationwide. So if the program is deemed successful, it could be expanded into additional regions. And then they shared some example goals around their health equity plan, which has to do with food insecurity. The goals for this initiative include no increase in ED visits and inpatient admissions related to complications from food-related chronic illnesses. They also provided an update to who's included in this provider network. They listed 52 providers were included and we were curious about what types of providers were in that count. So we have primary care physicians, nurse practitioners, physician assistants, obstetrician, gynecologists, certified nurse midwives, clinical social workers, psychiatrists and dentists were included in that count. And then we asked them a question about how their quality withhold was handled. And they stated that it exists, it is not considered until their final shared savings numbers are received. They are not baked into those PMPM payments that are going to providers. So they really don't even consider that quality withhold until they're after the end of the program year. Of all the support payments made to providers, the priority care program support payments are the only ones not considered in advanced and shared savings. I also wanted to touch on some key points, especially because there's so much public interest in vitalized health nine. So I wanted to draw some distinctions between Medicare ACOs and Medicare Advantage. A Medicare ACO is different from Medicare Advantage. Medicare Advantage is an insurance product and those who choose an Medicare Advantage plan are no longer enrolled in traditional Medicare. The Medicare Advantage company processes, adjudicates and pays claims. Rightfully so, many are wary of Medicare Advantage plans and in the case of a Medicare ACO, the ACO works with the provider and with Medicare. A patient is still a beneficiary of traditional Medicare and even though the funds flow between, the way that the funds flow between CMS and the ACO and the ACO and the provider may change, all claims will be processed, adjudicated and paid by CMS completely outside of the ACO. The ACO itself does not have the ability to deny claims. I also wanted to mention that the ACO REACH program is a type of Medicare only ACO that replaced the global and professional direct contracting model. This program of which Vitalized Health is a participant is intended to be an improvement upon the previous GPDC model. There have been some valid concerns about participants in that previous model known as direct contracting entities and in order to address these concerns, CMS work to make the following improvements to the ACO REACH model. So 75% of the governing body of a model participant in the ACO REACH must be made up of participating providers, whereas in the previous model, that requirement was only 25%. This means that in the ACO REACH that on the ground providers are steering the ship for the ACO rather than stakeholders who may have any sort of motive. An ACO REACH entity must also have a consumer advocate and a beneficiary, both with voting rights on their governing body. And the previous model did not have this requirement. CMS also responded to concerns of patient risk coding abuse by changing from a cap on risk score growth of 3% a year, year over year in the previous model to a 3% cap from a static base year, meaning that if the underlying demographics of an ACO do not change, risk scores can never grow more than 3% during the model performance period. Also, CMS stated that they are prioritizing increased vetting of applicants to the ACO REACH model in comparison with other CMS ACO models and has increased ongoing monitoring of model participants as well. CMS is monitoring model participants in the following ways. They monitor levels of care, here, they monitor levels of care provided to make sure that the ACOs aren't skimping on beneficiary care. CMS conducts compliance audits throughout the year, investigating beneficiary complaints and conducts beneficiary experience surveys, the cap surveys annually to ensure there isn't a change in beneficiary satisfaction. They also monitor whether or not beneficiaries aligned to the ACO are being moved out of traditional Medicare and into Medicare advantage. I'm gonna pass it over to Russ for this slide to walk us through a couple additional points, including the Green Mountain Care Board's process in reviewing these budgets. Thanks, Michelle. So just a couple of further points to kind of round out what Michelle was saying, and then I'll talk about the Board's authority. The first is under the REACH model, beneficiaries had the option of opting out of the data sharing. So CMS may share aggregated claims data about financial performance and quality for an ACO and beneficiaries can call CMS and opt out of that, having their claims data shared in that way. Just to make the point clearly, an ACO enters the market through finding providers who want to participate with that ACO. It's not a decision that ACO can make on its own. It's a joint agreement with a provider and it's voluntary for the provider and it is usually done on a year-to-year basis so the provider could back out depending on how the provider's experience with the ACO goes. So a couple of things about what the Board's authority is in this particular space relative to ACOs that have contracts only with Medicare and in these cases, there are also ACOs with fewer than 10,000 attributed lives in the state. So it's very explicit in the statute that ACOs that only have Medicare contracts are not required to be certified by the Board. Under section 9382A, certification is only required for an ACO to receive Medicaid funds or commercial funds. So what we're left with here is the budget review where as we look at the statute and the rule, the Board is tasked with reviewing, modifying and approving budgets which is unlike the certification where the Board may either approve, provisionally prove with conditions or deny a certification application. So under the current statute and rule, the Board does not have authority to prevent a Medicare only ACO from entering into the state. The authority for the Board to prevent an ACO from operating in Vermont falls under the certification provision which explicitly isn't required for the Medicare only ACOs. But also note, this is consistent with the enforcement provisions in the Board's ACO oversight rule. Those enforcement provisions set remedial actions that ultimately could culminate in the replication of certification. So if we think about the kind of ultimate enforcement as stopping an ACO from participating or operating in the state, the rule sets that up, that ability to stop the ACO from operating in the state as revoking the ACO certifications. I also wanna note here, as the Board considers the budgets of these ACOs, there are quite a few programmatic elements of the REACH model or the MSSP model depending on which ACO we're looking at that are set by CMS. And those are elements that are outside of the Board's authority to change their provisions that are determined by CMS in its rules and regulations. So making a similar point to that, the Board is regulating the ACO conduct in Vermont, we're not regulating ACOs operations in other states. So what we're left with here is using the budget modification authority and some broad kind of reporting authority that the Board has under the ACO oversight rule to require reporting and monitoring provisions of ACOs. And based on that authority, we've crafted some staff recommendations that Michelle is gonna walk through, which are sort of designed to help the Board monitor the financial and quality performance and results of the ACO in the state. So Michelle, I will turn it back to you, I think. Thank you. So I already spoke verbally to some of the safeguards that CMS has in place, but this slide has them here in writing. If anybody would like to refer back to this. So here are some updated staff recommendations for Vitalize Health. They may seem a little familiar. So recommendation one, Vitalize Health nine provides the Green Mountain Care Board. It shared savings and losses segmented for Vermont. Recommendation two, Vitalize Health provides an updated version of their Vermont financial summary. Staff, GMCB staff to develop the template and set the deadline. Recommendation three, Vitalize Health nine provides the Green Mountain Care Board its ACO reach quality reporting segmented for Vermont, if possible, with appropriate restrictions to protect patient confidentiality. Recommendation four, following three performance years in Vermont, Vitalize Health nine provides reporting for those years on GMCB specified metrics, which may include the categories of inpatient medical, inpatient surgical, emergency department, professional office visits, ambulatory care sensitive admissions and any other additional metrics. GMCB staff to develop the template and metrics and set a deadline. Recommendation five, Vitalize Health nine provides a semiannual update. The first support report submitted with their FY25 budget submission on October 1st, 2024 about how Vitalize Health nine's care model is working in Vermont, including any consumer complaints received from attributed Vermont beneficiaries. GMCB staff to develop the template. And the final recommendation, a representative from Vitalize Health nine must engage in an orientation led by the blueprint for health within the first quarter of 2024. Here I have some suggested motion language, move that the GMCB approved Vitalize Health nine ACO's FY24 budget as submitted to the board subject to the conditions reviewed by the board today. And at this point, I will turn it back to you, Chair Foster. Thank you both very much. I'll open it up to the board members for questioning comment and then we can see if anyone wants to make either of the motions, but I guess we'll take some board member discussion first or questions if there are any. Let me just ask one question. On recommendation five for both of the Medicare only ACOs, I'm wondering if there's any value in expanding the gathering of information about consumer complaints beyond just Vermont. So asking for all consumer complaints, not just those in Vermont, just to the degree that we can learn from what's happening in other states with these ACOs. So just a question for the staff on that one. I don't see any obvious obstacles to expanding that recommendation to include consumer complaints from their network of national beneficiaries. I don't see a problem there. Ms. Swarad, one, which is are we aware, are there any investigations or litigations or any sort of findings of any problems with either of these ACOs to our knowledge? Not to our knowledge, no. A comment that really is a reflection on reading a lot of the public comments, which is I hear the real concern of profiteering and healthcare delivery. And I'm very profoundly bothered by aggressive business tactics, whether it be for profit or nonprofit within healthcare. This is challenged because I really do believe that really the soul of this may sound a little tacky, but I'm honest with it, that I believe the soul of medicine is the art of medicine. And that real artful practice of medicine is most exemplified by the primary care, patient, provider relationship, where there's trust, where there's understanding, where there's comfort in having that relationship over time. And I'm a firm believer that that really helps people live healthier, helps people live happier. I think it probably reduces the cost of care, reduces unnecessary testing. I think there's literature to support that. So I guess my concern, my bigger concern with primary care is the opportunity to have that relationship as being eroded by the challenges that are facing providers of primary care and patients accessing primary care, whether it be through the burdens on primary care providers through prior authorization or compliance or compliance or reimbursements that are just really not keeping pace with the cost of delivering primary care. So I think, I hope that the ACOs that are, the primary care providers, the practices, the FQHCs that are joining this various ACOs are doing so, I think they're doing so because they need the financial support to continue to provide high quality healthcare to their communities. And I understand the frustration of that, that there's profit going away from Vermont to these organizations. But at the same time, it appears to me that the Vermont organizations are benefiting substantially with their mission of trying to deliver their care, that they're delivering. So that's just my general comment on these ACOs. Thank you. This is Tom and... Go ahead, Tom. Thank you. I wanted to just briefly echo Dr. Merman, the thing that struck me most from the numerous, several dozen public comments we got were the frustrations with not even profiteering per se, but a focus on finance over people and how frustrated that is for Vermont, frustrating that is for Vermonters and how much stress that adds. Some of the concerns that were raised caused me to really reflect on my understanding of what the ACO reach model does. And so I double and triple checked and I wanna thank Michelle and her staff for double and triple checking. This new model seeks to address many of the concerns of past models. And specifically limiting networks, upcoding, cherry picking, governance by administrators. This, the reach model specifically addresses those and really tries to take the features that have worked with ACOs that have worked. Those include keeping it small, keeping it focused and having it be provider led. And providers in Vermont have selected to join these ACOs because they think it will help them care for their patients. So I think that's important for us to reflect on. It's also important for us on the board to read the comments and hear the frustration in our community. And I did and I want to acknowledge that I read them and I heard it. I don't have anything else to add that others haven't already said. I do think the recommendations do a good job of staying within our scope, admittedly limited though it be and ensuring transparency and monitoring. So I appreciate all the work, Michelle and Russ that you've put into it. Thanks. Could you put up the motion language again Ms. Sawyer, if you can. Would you prefer the one for lore or the one for vitalize? Vitalize, I guess, since we're here and close to it. Mr. McCracken. This is a quick thing. I just wanted to note member homes change in one of the conditions. So the motion language would be changed slightly to say something along the lines of conditions reviewed by the board today with those changes discussed by the board today. So we can make member homes change in the final version. Yep, great. Thanks. And I agreed with member homes is change and I think that makes sense to broaden that. So I'll move that the GMC be approved, vitalize health nine ACOs fiscal year 24 budget submitted to the board, subject to the conditions reviewed by the board today and as modified by member homes is suggestion. I'll second. Did we lose the chair? He looks frozen. Oh. I'm still here. I didn't hear a second though. Oh, Tom seconded. Oh, okay. I might have glitched out for a second. Okay, great. So we have a second. Thank you very much. We can go through any board comments on the motions. I'm not sure there'll be much. I will just thank Michelle and Russ for walking us through and reminding us of where our authorities lie and the context of this review. So with that, is there any other board comment or discussion on the motion? Hearing none, I'll turn to the HCA as to whether or not they have any additional comment. Yeah, thanks, Jeff. Also just a brief one. Also wanted to reiterate and thank everyone that submitted public comments to probably no surprise that we think this engagement is important and helpful. I also want to thank Michelle and Russ. We agree with the staff recommendations and also with member homes suggestion that gets a good one. And we also agree with the board's analysis that currently a president of board doesn't have the power to deny a Medicare only ACO from operating in the state. I think for us, what that unfortunately presents the board is a dynamic of essentially voluntary compliance with regulation by these entities. I mean, I think what we worry about is these well thought out recommendations. Entities like law or vitalize could simply choose to not comply with it. And I think the board's lack of authority is something that the board could address through a rulemaking process that we outlined in our comment. So thank you. Great, thank you. And I'll open up to public comment. Ms. Wasserman. Yes, thank you. Julie Wasserman here. I guess my comment is more overarching. I concur with all of HCA's thoughts and comments. I guess my one comment would be that we've got problems in Vermont when FQHCs need to resort to this model. And I think that this discussion and the actions are quite to some serious problems in terms of the way Vermont treats primary care. And I'm hoping the Green Mountain care board maybe in the future can address some of these issues so that other FQHCs and other primary care practices, independent ones won't be forced or have to resort to a for-profit model just to maintain their existence. Thank you. Thank you. Walter, I saw you come on camera. Did you have a comment? Hey, a couple. Two-year question about litigation with Vitalize. Dr. Marvin Malik sent in a commentary that I read. I read those public comments too about the history of the founders of Vitalize, which was really pretty telling about their motives. I agree with the ACA that these people can just skirt regulations or recommendations whenever they want to. And I agree with Julia on her comments about the motives of the private firms and the state of primary care. And I also want to back up what Dave said about the relationships as a patient. It's always strained about, because you know these private companies are coming in calling you, you know, managing, trying to manage your care and then building it to Medicare and then you wind up getting build yourself for something you didn't know about because it's all about the money right now. It really isn't anything about the patient per se anymore. It's how much the patient is a source of revenue. And I don't see, I wish the board did have the authority to knock back Vitalize or Lore because I don't see them doing anything really for us except siphoning out our dollars. I did want to back Dave up on that comment because as a patient, it's really hard right now. Thank you, Walter. Mr. Barter, and I'll just try to introduce people from where they're affiliated with. And I believe you're the CEO of Little Rivers. Please go ahead. Thank you, Chair Foster. That's correct. I wanted to thank the care board and all those that participated in the public comments. We appreciate what's been discussed and we hear the concerns in the public comments. They're helpful for us as we find our way. I also want to reassure that no external entity will intervene with patient-centered care here directed by our providers solely. That will never change. And we hold to that. I also wanted to give just a quick story on how we got here in terms of our health center. I could give a long story, one short one with respect to everyone's time. Our understanding historically has been that our particular health center due to geography and the health service areas may not be ideally or practically aligned with programming at OneCare. And so we ended up in a situation where we haven't been a participant in value-based care transformation and with OneCare Vermont and haven't had that component of to help us with quality and also with the sources of revenue that come with that. And so we did engage with set up activities with Vitalize this year and anticipation of participation some or all of next year. Our engagement, it may be termed at any time. I think we're both presumably motivated to follow the morals and the ethics of Little River's healthcare. But if by any reason we deviate from that, then we will discontinue our participation. I also want to share that we have engaged directly with Green Mountain Care Board in some conversations and anticipate continuing on that path. And we have met with a bareman and Carrie Wolfman from OneCare Vermont. And we're very hopeful to, it's our understanding that the comprehensive payment reform program may be extending from private practices to FQHCs in the course of 2024. So I just wanted everyone to know that we're thankful for all the conversation. We're committed to our patients. We want to be part of the movement in Vermont with Vermonters. And that's it. Thank you. Thank you very much. And thank you for providing the public comment to give the board a little more information. And thank you for all the public comment that we did receive. It was well done and informative and made the board really look hard at this. So thank you. Any other public comment? Okay. We have a motion. It's been seconded. All those in favor, please say aye. Aye. Aye. Aye. Aye. And the motion carries unanimously. Ms. Sour, would you mind pulling up the staff recommendation for lore real quick and then we can go to the motion language? Member Holmes, would you want to expand number five as to these recommendations as well? Yes, please. All right. If you could pull up the motion, please. I move that the Green Mountain Care Board approve Lore Health's ACO, Lore Health ACO's fiscal year 24 budget as submitted to the board subject to the conditions reviewed by the board today and as modified by member Holmes. And is there any board discussion? Does the healthcare advocate have any comment on the Lore Health motion? Nothing else, thank you. And is there any public comment? All those in favor of the motion, please say aye. Aye. Aye. Aye. And the motion carries unanimously. I think that's all we had on the agenda today. So I'll ask whether there's any new or old business to come before the board. And a big thank you to our staff who really worked extra hours last month and really last week on these presentations to provide the board a lot of information and a lot of things to think about and consider as we evaluate the one care budget going forward. I appreciate that very, very much. And I thought the presentations were very, very helpful to frame our thinking as we move towards a vote and deliberations. Seeing there's no new or old business, is there a motion to adjourn? Yes, I move to adjourn. I will second it and all those in favor, please say aye. Aye. Aye. Aye. Motion carries and we are adjourned. Thank you and have a good afternoon.