 if everybody could get a seat, and before I turn it over to the executive director for the executive director's report, I did want to acknowledge that we're very fortunate to have two legislative committees joining us today. We have Senator Lyons and the Senate Health and Welfare Committee and Representative Lippert in the House Health Care Committee. We're very happy to see you. We know that this is a very busy week as you approach town meeting, but thank you for attending. Susan, the executive director's report. Yes, thank you, Mr. Chair. So welcome and thank you everyone for attending the Green Mountain Care Board. Just a few words about today's meeting. I'm really excited to hear from our panel and hear the reports from the field on the all-payer model. The all-payer model, as many of you know, was signed at the end of 2016 and we're well into the second year of this model and I think it's going to be interesting to hear from the frontline workers, the providers, the communities on the work that they're doing, their successes, and perhaps some of their challenges. And here at the board, as many of you know, we do our regulatory, statutory work every week, but because we have this open public meeting space, this is a great opportunity to have an educational panel such as this and I, for one, am very excited to hear from our panelists and I know Board Member Holmes and Chair Mullen will set that up after I turn this back to them. I do have a couple of announcements. Number one, Gifford Medical Center has requested an amendment on their budget. Make sure I get this language right from my general counsel here. So that information has been submitted to the board. The staff recommendation on the request will be posted on our website by March 7th and the board will be hearing from Gifford on March 13th. That meeting is going to start at 9 a.m. and I would just put out there if folks have any public comments on that material when it is posted, we would welcome that. There will be a potential vote scheduled for March 13th. The other announcement and update I have for the public is that on Monday of this week we held an advisory committee meeting and this was a newly formed advisory. We over the last six or seven months have been looking at reimagining the advisory committee meeting, advisory committee, and we held our first meeting of the newly formed group on Monday. It was an introductory meeting, but we were very impressed with the broad and deep knowledge that these members have and we are looking forward to working with them and being advised by them. Our meeting schedule for the advisory committee is scheduled, is posted on our website, and I'd encourage folks to take a look at the members. They're quite impressive. And I think that's all I have to announce of one more important announcement. Next week we do not have a board meeting. It is town meeting week. I see smiling faces. So I just wanted to announce that as well. And thank you. I'll turn it back to you. Chair Malin. Thank you Susan. So I'm going to quickly turn it over to Dr. Jessica Holmes who has put together this panel. I know that the legislators are on a short period of time, so I want to leave as much time for them to hear from the panelists as possible for them. So Dr. Holmes, thank you for putting this together. Great. Thank you so much, Terma. And a sincere thank you to all of you who are taking the time to spend with us today. I know all of you have busy days, and particularly I know the panelists who have prepared some stories to share today for taking the time that your insights on that may be invaluable. And I wanted to set the table a little bit. The goal of today is to enhance the boards and the public's understanding of the all-payer model. I share a real human story about how the delivery system is changing on the ground. As we all know, Vermont is on the cutting edge of healthcare reform. Policy makers from around the country have their eyes on Vermont as we transition from the fee-for-service reimbursement system that basically rewards volume and not quality towards a value-based payment system, a reimbursement system that is rewarding quality care coordination, primary prevention, and population health. And as we've said many times at our board, giving us innovation, disruption, and full-scale change in how we pay for and deliver care will take time. So as Susan said, we're in year two of a five-year model. We need patients, a lot of patients. But as the incentives and the system change, so should the allocation of resources. So seeing changes in resource allocation and how care is delivered will tell us that we're on the right path. So we should start to see the system reallocating resources to interventions that have the greatest impact on population health. The shift of resources towards the most cost-effective services, which may not always be medical care. In some instances that may be social services. We should start to see the system changing how care is coordinated and how care is integrated across the system. And we should start to see the use of big data. Now the technology allows that to help focus our resources on the most vulnerable to models. So the board recognizes that many communities are already making these significant changes and we want to learn more. So we put together this incredible panel I think to help share with us what's happening on the ground. So we have Dr. Steven Leffler, who is the Chief Population Health and Quality Officer of the UDM Health Network. We have Dr. Joe Haddock, who is an independent practitioner at Family Medicine at the Thomas Chittenden Health Center. Carla Camel, who is the Community Care Coordinator at Mount Ascutton Hospital. And Jill Lord, an RN, who is the Director of Community Health at Mount Ascutton as well. Dr. Kerry Wolfman, who is the Chief Medical Officer at Porter. And Allison Worst is the Director of Population Health and Care Management at Porter Medical Center. Judy Peterson, President and CEO of Home Health and Hospice in Chittenden County. Dr. Elizabeth Fontaine, who is a Lifestyle Medicine practitioner at Northwestern. And Dr. Judy Fingergut, who is a Family Medicine practitioner at Northwestern as well. So I'm going to kick us off with a few questions. I'm hoping for a casual conversation. It's hard to have a casual conversation when we have, you know, lights, cameras, and action here. But as casual as we can possibly be, really, I ask for no presentations because I really want this to be a storytelling session about patients. I really want the focus here to be about what is happening to patients, what is happening to their monitors. So with such a large panel, I'll ask a few questions. Don't feel like you have to answer every question. There's enough people up there that I'm sure the questions will be answered by some subset. Then we'll open it up to the board for some follow-up questions. And then finally, we'll reserve some time for public comment to make sense that people want to share their experiences or their perspectives. So with that, are we ready? We're good to go. All right. So my first question involves this movement from Feed for Service. So how has the movement from Feed for Service to fixed payment changed how you deliver care in your communities? Are there examples of increased investment in particular services or personnel as a result of this transition to value-based fixed payment? Any increased expenses on time-right care or social determinants of health? Those are the kinds of investments we'd like to see this model create. So you can share some stories about that. But I don't know who wants to go first. You want to go first? Okay. You can go first. Good morning. And thank you to the Green Mountain Care Board for inviting me to share a success story in services that we've invested in primary care at Northwestern Medical Center. So I'm going to spend a few minutes sharing with you a success story of our care coordination services at our primary care site. I'm a family physician. And back in November of 2017, I had the pleasure of meeting patient WD. He came to me as a new patient after his long-time physician retired in the community and was establishing care at our center. Right away he told me he's a diabetic and he apologized for the fact that he would not be able to give me a good history because his wife is usually the historian but wasn't present at the visit. I went ahead and checked his A1C. For those that are not familiar, A1C is how we measure how well-controlled a diabetic is. A well-controlled diabetic is someone with an A1C of less than 7%. His in the office was 11.5% and that's significantly high. Very uncontrolled diabetic. I asked him, what meds are you taking? He tells me he's taking, he's supposed to be taking a medication called metformin but can't take it because it upsets his stomach and he's taking a second pill, doesn't know the name. I asked my medical assistant to please call the pharmacy so we can get some more information. The only medication the pharmacy had on file for him was the metformin, the one that he's not taking. The second pill was not on that list. So I could not do much for him at that visit. I asked him to please have some lab work done, bring in all his medication bottles and I would see him back in two weeks. He comes back in two weeks, his lab work wasn't done, didn't bring his medications in. I asked him, how are your sugars at home? Are you checking them? He's like, I no longer check my blood sugars, I don't have a machine. Then he informs me at this visit and apologizes again that his short-term memory isn't really good because he had a cerebral aneurysm rupture a few years ago and that affects his short-term memory. So I discussed with him how I think we should proceed with this treatment and given that I needed to keep his treatment simplified and avoid a lot of medications, we decided that insulin would be his best choice. So I wrote out prescriptions for his insulin, his blood glucose machine, all the supplies, referred him to our certified diabetic educator who is embedded in our practice and I asked him to go pick up all these supplies at the pharmacy and to come back that same day so we can go ahead and do all his teaching. He didn't come back that day but did come in to see the certified diabetic educator a few days later and all the teaching was done to meet the patient with his needs, keeping in mind his short-term memory deficit. All of that by step instructions were sent home with him and first insulin dose was done in the office. I asked him to come in three days later to see how he was doing on his insulin. He informs me he didn't start his insulin. He was nervous but his wife was willing to help out but she didn't come to the visit. So I said no worries, we'll go ahead and do the teaching again in the office and I referred him to our nurse care coordinator who's also embedded in our practice to set up a home visit to meet the patient and his wife at the home. So over that weekend my nurse care coordinator went out to visit and the wife wasn't available, the patient was there and he was unable to properly demonstrate use of the glucometer and was really frustrated that he just couldn't get it and he wouldn't use the insulin until he could master using the glucometer. And finally after about a month we were able to do a med reconciliation at home because he kept forgetting to bring his medications to the office. He comes in to see me a few weeks later, insulin still hasn't been started and I encouraged him please bring back all your supplies. Our nurse care coordinator will go ahead and help you with all of this. He comes back in and sees the diabetic nutritionist. So all these services we have in our office and he's reporting now that he's only been injecting a couple of days of insulin and wants to make sure he's doing it right. So our nutritionist along with the nurse validated that he is doing it right and they went ahead and encouraged him please use it every day. So he comes in and sees me and he is consistently using his insulin every day so I begin seeing him less frequently every one to two months. And our care coordination team which includes our nurse care coordinator, our certified diabetic educator, our nutritionist, myself all ensuring that he was following up on all our recommendations. Five months after he started insulin he went down from 11.5 percent down to 8.6 percent. I'm like perfect now we can start working on your other health problems. His high cholesterol, his fatty liver, his sleep apnea. Seven months after we began the insulin his A1C is down to 6.9 percent. He reached his goal. But then at that visit the challenges don't end. He informs me he can't afford his medications and it's at this visit that we realize that he didn't have any prescription coverage. So our social worker embedded in our practice met with him that day and began the enrollment process for Medicare Party. And $72.10 with co-pays is what it would cost him to pay for his medications every month and he was okay with that. But the caveat to that was that with this insurance his insulin that I had prescribed him was not covered and so we had to switch him to another preparation. Unfortunately he didn't have any challenges with learning how to use that particular preparation. While all this was going on and this is the end of the story for now he developed some lower back pain and some weakness in his left leg due to some spinal stenosis of his lower back requiring him to use a cane to walk. And so I was able to send him to the pain interventionist who was able to give him a steroid injection in his back because his diabetes was well controlled. If he had presented a year before with these complaints he would not have been a candidate for a steroid injection. It was successful in terms of relieving his pain about 50% and so now he's going for back surgery and again this would not have been possible if his diabetes, his glycemic control was not where he needed to be. So I just want to summarize through the efforts of our care coordination in our office, our end care coordinator, our social worker, our nurse supervisor, our certified diabetic educator, our nutritionist, my medical assistant and the perseverance of my patient and he was able to take control of his diabetes that he was able to identify barriers and help him work through those barriers. His quality of life has improved and I really hope he has a successful back surgery. Thank you for your time. What that's consistent with what we've been seeing at the board with the hospitals that have moved to fixed payment and actually hiring personnel in areas such as social workers in emergency rooms putting mental health clinicians, nutritionists in primary care practices allowing that care coordination to happen. So thank you for that sort of consistent of what we've been hearing. I'm wondering if somebody else want to jump in and think about, help us understand how that movement from fee for service where you're generating more volume to a fixed payment has allowed you to have some flexibility of resources to do different things. Hi everybody. My name is Judy Peterson and I want to start out by saying I've been a nurse for over 50 years and during about half of that time I've been in administration. This is the most exciting time in home care that I have ever experienced. I'm retirement age, I don't want to retire. It's too good. All the good stuff is beginning to happen and that's really because the healthcare reform movement here in Vermont from the very beginning, our ACO One Care Vermont engaged community organizations as partners so it's really given home health the opportunity to begin doing some of the things we always knew were the right things to do but we didn't have payment for them and I want to give you one quick example. In Chittenden County in our home health agency we're doing a program that we call Longitudinal Care. For a long time we had recognized that most of our referrals come from hospitals after somebody had a hospital stay so we do the post-acute work. We help stabilize people. Often Medicare would pay for that if people were eligible for Medicare but then as soon as they became stable they're no longer eligible for home health services and we knew that oftentimes that stability would not last very long. We would have been visiting somewhere between 30 and 60 days doing all the kind of things about the medication management education really helping people access other services in their community but in 30 to 60 days you heard how long it took for Judy's patient to really get on the right track well that's exactly what happens with other people so One Care now provides care coordination dollars to home health agencies and so we're using that money to do a program to actually fund ongoing care for people even after they're no longer eligible for Medicare so when they were on that skilled Medicare service they were getting nursing visits a couple of times a week maybe a home health aid maybe physical therapy but so when they're discharged from Medicare we keep them on the home health agency services so we still provide a nurse oversight we do tele-monitoring which is kind of an electronic look it's like an iPad that's in their home that will send information back to the home health agency where one nurse monitors about 80 tele-monitors in homes and it gives us the person's blood pressure, heart rate oxygen levels and their weight which are really essential data to be able to manage people with certain especially cardiac diseases so in any event now that we're doing this program there's community health workers who are a new discipline of people who they're not LNAs doing licensed nurses assistants doing personal care and they're not nurses doing all the assessment but they're really coaches for the patient and they're able to visit a couple of times a week in the home so we have in December we looked at the past year how did the people on our program do and our 20 patients on that program we compared the patients on the program with 12 months prior and we reduced hospitalizations by 30% and reduced emergency room visits by almost 10% so that's a huge cost savings and this is not an expensive service and it's really doing the right thing at the right place for the right at the right time so I'll give you one quick example and then I'll pass this on a woman named Linda she's 67 years old prior to coming to this program she had had nine trips to the emergency room and three hospitalizations in the past year we provided her with monthly nursing visits the telemonitor support so our telemonitor nurse would be able to contact her if she saw readings that were getting out of whack and a community health worker visited also and they did a lot of health coaching disease management and since so in the year that she was on service she only had one hospitalization and that was for she went to the emergency room for abdominal pain and actually had an admission for liver abscess so it was something that was very appropriate for acute level care the quote from Linda is and she was somebody who was constantly using health services when not at the ED or having hospitalization she was at her primary care's office and she said I haven't needed to go back to my doctor for months now and I've even walked outside with our dog so we're talking quality of life also for patients and anyway it's just I could tell you many many stories but I wanted to at least share that one I can hear you can everybody hear? maybe use the microphone I just want to add a little detail to Judy's story so there's two parts to that for the UVM medical group for our primary care providers family medicine internal medicine we've changed their model from volume based to a panel size based so that frees them up to not have to see every patient six times a month to get their salary in the past for most of my career in medicine we had a volume based model so you had to see a certain number of patients per year doing a certain number of procedures to get your salary for our primary care docs now we've give them a risk adjusted panel and their job is to keep that panel as healthy as they possibly can if the most efficient way to do that is with a phone call that's how you do it if it's doing it through my health online and emails back and forth if it's a visit if it's a specialty consult now you're paid to keep your panel healthy in Judy's example we're actually diverting dollars from our primary care dollar capitation budget to the V&A for this longitudinal care pilot the way they have waiver works we're allowed to put some dollars and keeping people healthy in their homes is a very good investment in the new model so I want to say that the reason that can work is not only one care which allows us to do this gives us the waiver but it's now makes sense for that primary care office to have the V&A keep going after 60 days I'll stop on the way down the line here so I did want to talk about systems development because there has been a change in a shift in the way we approach patient care and care coordination you know you think about one patient at one time in front of you and the shift is now from yes we continue to do that but also we get a list of the high risk and very high risk patients that's been able to be determined through diagnosis through medications through ER visits through inpatient visits so we know the people that maybe we haven't been seeing but they've been using the system so we're able to as a team picture a group of of nurses social workers people from the V&A people from SASH people from the other eight community agencies that we work with HCRS saying okay this is their list of people who's working with them who's on the team who needs to be on the team how can we organize ourselves instead of working in silos we can build systems to approach this systematically reach out to people that are being seen currently right now and we're developing stronger relationships I'm looking out into the audience and seeing George Karabukakis from HCRS and you know our our partners are invested in a new way to help us help keep people healthier and we're able to do what we can do and V&A is able to do what V&A can do and we both know who's doing what on the case because we have joint care plans that are facilitated by new systems of electronic capability through care navigator so care navigator for folks who don't know is one care software platform right that allows coordination of care so now we can jointly contribute to a care plan we have to be honest with everyone we're babies in this so we're building a system it's going to take time to evolve but the partners are together around the table and we have as well as understanding through professional judgment the patients like you talked about that are high risk we can also have a list of people that we aren't seeing that we can reach out to and the people that we weren't aware of the number of emergency room visits I think the other thing is that's changed is we're looking at a model of care so that and I just have to say through one care Vermont that the quadrants of care of understanding who are the well who are the at risk who are the complex who are the very high risk patients so that we can look in a model of care and concentrate efforts on prevention to keep the well well you know to move the people that are at risk keep them towards the well and to move everybody in the continuum of care towards healthy behaviors and you heard that when you heard about the A1C that went from 11 to 6 you saw we see that in front of us we also can see it as a system and as a model that looks at population health I want to compliment one care for the investment in Rise Vermont we're able to really look at nutrition and exercise at a community level and build systems in place working with our food shelves working with our rec departments working with new community partners instead of working in silos in ways that can set up systems and culture change that can emphasize health and healthy behavior again keep the well well so I would agree with is it Dr. Peterson the nurse Peterson I too and I say that with all of the admiration I'm a nurse to for over 40 years and and so we're sisters in this it is exciting times to live because it's changing the way we can approach health care to really change moving towards health as a system and working instead of silos working with community partners I think the analytics that one care has provided I never thought I'd see in my lifetime we can get reports both on individuals and on our population at large that we haven't been able to see and use before so we have a true picture of who we are and where we need to go thank you hi thank you for giving us the time to come and share our clinical experiences and input I've been a family doctor for 25 years and I have to agree with Judy it's the most exciting time in medicine for me given the opportunity to start seeing patients from an entirely different approach instead of sitting in my office and hoping somebody needs me or has a problem and needs to come in I now am able to utilize a lot of different resources as well as aspects of our medical system to help promote wellness and prevention and that is extremely satisfying in this profession I would say I wanted to share a couple of points one is to tag on to what Dr. Lefler said about changing our compensation model at Porter as chief medical officer and also now involved with the medical group at UVM as of January our physicians joined that medical group we asked to be in a pilot study so that our primary care providers could be compensated partly for quality which had been going on for about a year so about 10% of our compensation comes from quality metrics and we asked for another 10% to come from population health metrics and we came up with a list of nine population health efforts or QI projects and asked the primary care providers to choose two of those and their pay is connected to that now and some examples of that are promoting advanced directive completion follow up after hospital or ER visit for a mental health problem within 30 days we asked the physicians of care coordination educating our staff and each other about population health management wellness and prevention and how to promote that in our community getting involved with the MAT program locally so I find all of that very inspiring and thankfully the providers have gotten on board with that at Porter about I'm changing topics now about five or six years ago we started a palliative care program which failed I think because we were very aware of our fee for service model and it didn't pay for itself and so now we are excited that we have a palliative care physician again two days a week soon to hopefully be four days a week in our community helping our patients plan for their end of life working with families coming up with a shared care plan I can give a story about one of my own patients who in her approximately 80s had chronic reoccurring pancreatitis and was in the hospital several times in the last year of her life but because of our palliative care service was able to make a plan to go home with home health have all the services she wanted at home and the very last time when she could have gone to the hospital made a comfortable decision to stay at home which was her desire and she passed at home but even at the end my office was called and I was asked to go to the hospital and I said no we have this wonderful care plan in place everybody's on board and that's what she wants so it was great to see that happen and I'm glad that we have additional resources through our involvement with one care in the all care model to do these kinds of things just be going down the road so go ahead Allison so I'm Allison Horst I'm the director of care management and population health at Porter and I'm also a nurse recently I worked in the emergency department and so I had a an example of a case that really hits on a few of my loves both the emergency department as well as complex care coordination so through the financial support of one care as well as the changes in incentives around our payment model and including some really good support from one care in developing programs around complex care coordination we've created several positions at Porter hospital for outpatient complex care managers and we've also seen similar changes in staffing in our designated agency the counseling service of Addison County so they have a new these tend to be very flexible kind of nebulous positions where we have folks who are qualified to do assessments of patients and kind of meet folks where they're at but don't really fall into the roles that existed prior to the payment reform we are highest utilizer of the emergency department is someone who has significant mental health needs but also does have complex medical needs as well and so she was someone we always had in mind as we were developing these systems both for the counseling service as well as for the outpatient setting in October of 2018 we were able to both someone from the counseling nurse from the counseling service and a social worker who was newly hired to provide support in complex care coordination in the primary care office we had a visit with this patient in her primary care setting with both again mental health and social work support and we're able to really formulate a good care plan for this patient in looking at the three months prior to that initiation of care coordination the numbers are decreasing if you don't work in an emergency department but in the three months prior she had 42 emergency department visits and five office visits after we started implementing this complex care coordination we really shifted that significantly so still very high utilization of services but her emergency department visits were decreased by half and that care shifted towards the primary care office and the mental health clinician who was in mental health services the other sort of thing that's not easy to capture in numbers is the emergency medical services so for someone living in a fairly rural area this had a huge impact on the ability for EMS to provide service to that area they were very frequently driving her to the emergency department so that was really impacting their ability to provide care across the board and really more importantly the emergency department was not providing that was improving her quality of life it wasn't addressing the real issues that were going on it was very fragmented care and so while her utilization is still quite high at this point it's really focused much more in her medical home focused on her mental health and has really significantly improved the quality of her life I mean this is only a brief snapshot in time and I realize this isn't like a you know case closed victory can be declared kind of a situation it's a really good example of how really intensive focus of the right kind of services for our most complex patients can have a really huge impact in many services good morning and Dr. Elizabeth Fontaine just want to make sure that you understand that I am doing lifestyle medicine but I'm also the medical director of Rice Vermont so I work in the other quadrant in the majority of people here I'm definitely in the primary prevention wellness which I've done for many years I was an obstetrician gynecologist for 25 years I saw my patient getting older with me and having some chronic condition addition to what was going on they went to their primary care that helped them to tell them that something needs to be changed but eventually they would come back to me on medication I was a little uncomfortable with that my previous studies when I was in Canada prior to medicine were in exercise physiology and obesity so I started helping my patient easily in my office actually I had a clinic where I was trying to help these women with significant improvement under that time I was on myself I was not with the hospital so on this base model lifestyle medicine is very difficult because there is no payment really model to help people with their lifestyle so I will continue with something else I'll come back with what we've done at the hospital but I just want you to know that lifestyle medicine is a specialty that exists it's been there for over 10 years there's now a board certification that exists since last year so I'm a board certified in lifestyle medicine there's also another physician in Springfield Dr. Scott Durgan who's also certified in lifestyle medicine so the work of the primary prevention with Rice Vermont Rice Vermont is a movement it's a community based intervention we tried to help people to change their lifestyle we started that in Franklin Grand Isle with implementing health coaching we amplified what people are doing into the school, community, businesses and it's making a difference to the point that we succeed to work with OneCare and expand this model since last year in all the different community the state team is doing an amazing effort and I'm proud to be working with them as far as the lifestyle component actually I did some work by myself but eventually becoming an employee of NMC I had the chance to try to work with them actually it's in 2016 that we came and asked the Green Mountain Care Board to revisit a little bit the cut that NMC had and say listen can we have a little bit of this money back to work in primary care and we did you know when you have what is possible you can do some amazing thing so a lot of people that have me my work in lifestyle is basically more into the early secondary prevention where people are starting to move into the second quarter this is the best time to try to bring them back when you think about it one of the biggest thing is that 86% of our healthcare costs is chronic disease 80% of that is related to our lifestyle the cost is increasing not because of the healthcare system it's because of us in our lifestyle we need to make those changes but to make those changes is not easy many physician and try to tell them once is helpful but these people need to be assist they need to have people help them to make those changes so we've implement into my group having some health coaching which is an evidence based model recognize at the national level we work on self determination self efficacy motivational interviewing is always you know part of that but you know the way to change the individual is to work on their personal intrinsic motivation it is not me Dr. Fountain that will change him it is you that will bring I'm going to bring you to your best self and then we can make those changes so when you succeed to make those changes in 2016 that help us not only to improve care coordination we took some money that will allow it to continue with that to stabilize rice Vermont and to lifestyle I brought some program that we call chip it's a complete health improvement program that educate people into nutrition it's a nationally recognized program there's over 80,000 people that were successful of changing substantially their lifestyle and improve you know their result of chronic disease reversing and preventing chronic disease I've done about seven group of this chip program the actual group that we're doing is with eight individual and maybe one story is this young guy because usually it's women that participate but for a change I have a young man who's 26 62 had cholesterol at 350 with his bad cholesterol LDL at over 180 well by changing his diet with this education in the family history he was very concerned about his father with these change in three weeks we recheck his number everything was back to normal lifestyle we need to change that it is feasible so now what we're doing is after doing this implementation of a lifestyle clinic with my patient with a nice hand onto the life coach we're now trying to implement this model into primary care and I'm going to be working with Dr. Finger in order to help her and her patient kind of a community approach a quick question for you and then I'd love to hear from the other panelists that haven't spoken but do you anticipate because we've moved away from the Secret Service model towards this value based model now you have lifestyle medicine at Springfield and Northwestern do you anticipate that this model is going to spread throughout the state to the state because now there's an incentive I think so and that's my hope I never anticipate that I would do that before the end of my career being a specialist in the second I didn't anticipate that so we're really trying to pilot the model and see if this is working obviously with my partner family practice I would love to see it expanding to the state Dr. Haddock She's better than me Hi I'm Carla Camelot and I'm so pleased to say that I work for Mount of Scotney Hospital with Jill our community health director leader and she really pulls together our partnership for community health I'm also thankful that I work for Mount of Scotney Pediatrics and also at the Auto-Quiqi Health Center as the care coordinator and I'm totally a boots on the ground person I'm out there in the community networking we hear about silos we formulated many partnerships within the community I go once a month to the Woodstock High School and the entire school staff of principals, psychologists counselors school nurses come into a team and we start on prevention who are the high risk students get a release we start formulating on plans I go and visit with the parent and the family to start that process and we filter back and network so that's one piece of the partnership I also complete hours over at the Thompson Senior Center in Woodstock where I'll get referrals coming in but also following up in the home I have to say that what I'm hearing and have heard for the past five years from patients thank you for coming to the home thank you for listening and also thank you for getting to know who we are and then I also go back and we'll share that with a primary care physician I have lots of stories I could tell you to go on and on but to speak to a few on partnership and also on team modeling and bringing people together so in pediatrics we've had some extremely complex care children and not only in their physical health but also mental health and speaking quite just to trauma these children have been extremely traumatized a couple of the patients that we share on one care care navigator the children both have been into disabilities such as the Brattleboro retreat in and out with the parents coming back to the table and this week for instance we just sat down with DCF the foster parent the child's therapist and the guardian and our pediatrician and the success from two years ago is amazing this child is thriving not only because being in the foster home right now that they are but also because they were wraparound services everybody was connected to say what are you going to do what are you going to do who's the lead in this case and let's sit back down and discuss what's going to be for next steps the other child also came in a few weeks ago with their foster mom DCF came in with a pediatrician and he also had his siblings there this child went through some really significant physical abuse and some trauma through their parent being totally involved in the drug world he is now thriving because everybody stepped up to say okay let's take a look at what needs to happen long time coming but it's whether very stable foster home and they just they love him to death and he's succeeding once again not only in the physical piece but mental health a long ways to go but we're getting there I also go to with Twin Pine housing in Woodstock and I'm there every Monday morning for a couple of hours and Twin Pines built affordable housing Stafford Commons and so I've gotten to know through each Monday just checking in with tenants who are most of our patients at OHC and I have to say some who have not did not have a primary care physician I've encouraged them to make sure that they have a primary physician so that's been of help as well but everyone gets checked in on we have some very complex cases with eviction and I know HCRS has been helpful in a couple of cases we had elderly lady and this is a work in progress still but I feel we've gained some success her apartment was totally infested with fruit flies I've never seen anything like it substance abuse alcohol abuse work in progress the check-ins just having that respect and trust has taken a long time I can say this week we've made a lot of brown work I've spent a lot of hours on the stairwell saying I'm here if you'd like to come out and speak with me so that's taken time her case manager she just they got back together to take her food shopping I'm taking her to her medical appointments to make sure she gets there that's the other case transportation a lot of people will say I don't have a ride not a problem let me look at your schedule my schedule let's just get you there and not only I will I get you there but I'm going to sit there with you if you'd like me to because we all know when we get there we don't always walk away saying what did what was I just told what am I supposed to do but making sure that medications before they leave the house so that the physician and the nurse can check in with them yesterday we made or two days ago we made bright strides and just speaking of how the networking goes we have a case and that the autokwitchy health center where we have a patient with intense schizophrenia morbid obesity diabetes and they live in an area that's so remote that they're not able to get out during the winter time and they don't want anybody at the house they've abused 911 services I believe it's been six calls within a very short amount of time and the patients when they get there says that they want food law enforcement has checked there's plenty of food in the house so what this came to is like how can we help this patient we all met myself and the HCRS team met the other day to say we're formulating a plan let's start working on this Carla if you could do weekly calls to the patient because the patients always calling the health center and really tying up important time and we're going to have somebody call the case manager call in and do weekly checks to get the foot in the door and then the therapist they just assigned not only the patient but her spouse to meet with the therapist and then we'll go through the psychiatrist but what I want to say how important that is because it's already worked I can see that from yesterday and speaking to the patient to say we all care about you and we're all working on a plan for you and you're going to be a part of this plan as the director so that's going to be a long ways coming but just listening to the family yesterday that's so important so the bottom line is yes we do get out of the silo but if you're in the community and talking there's even business people that want to be of help so you use your other resources to make it work for the patient thank you bring us on my name is Joe Haddock I've been in primary care in Williston for over 40 years and I'm self-employed I would say and to several people in the audience that I've been in meetings with for a long time are well aware that my goal is not reforming the whole healthcare system but I realize that primary care will form the basis for any new system that evolves and so my goal is to try to preserve primary care for primary care practice and independent primary care especially not changing the system is the worst thing that can happen and I'm convinced of that I will say there's been a lot of all-payer Kool-Aid served up here and I didn't mean that pejoratively and we at the Thompson and Health Center now is it all right to talk about the pilot yes absolutely so we at the Thompson and Health Center we sip on the Kool-Aid a little bit in this overall broader all-payer thing that's occurring but we evaluated last year and we decided we would drink a lot of Kool-Aid and be a part of an all-payer model pilot for which about 30 to 35 percent of our total patient population of 18,000 is attributed the question here is has the movement from fee for service to fix payment changed how our practice is well I can't say that in the broader picture is but through the pilot I would say it really is so that's a little different and it's a subset of this whole program and what changes I gotta be honest what changes how you deliver medicine how you deliver care to people how you coordinate care is money and it doesn't matter what system is and primary care and all these other services offered there's gotta be money somehow so I'm going to wind up with this pilot and I will say for the state again off subject a little bit the blueprint has been a wonderful thing in this state I would say it's not lucrative and for smaller practices it costs more to qualify for it then you get out of it money-wise but through for our practice embedded social workers embedded nutritionists and diabetic educators people seeing that they got their visits made the blueprint's been great again not lucrative the barriers to go into primary care two one is reimbursement the second is the large burden of administrative bureaucratic overhead so the pilot increases the latter a little bit the former moment I'm sorry the blueprint does that the pilot has worked out well for us without increasing our bureaucratic and administrative burden has resulted in a better financial picture for our office and our abilities to start a couple of new programs I was asked to talk about a couple of those one of those is we've had a you have to give away your oldest kid to get a psychiatrist in this state so we have started out there two days a week embedded in our office two doors down from mine and she sees patients from our practice we use the money extra money we got from this program to start up her program we use it to pay her to see patients whose insurances won't cover it unfortunately MVP doesn't cover it if you don't have nine or twelve experiences the years of experience we've done that and then it was so successful that one of our nurse practitioners who has 25 years experience we kind of supported going back to become certified in psychiatric nurse practitioner is that a word this year and so she's going to stay in the practice and do that a couple of days a week so we then have four days a week as it's planned of embedded psychiatric help for patients and patients without insurance patients with insurances won't cover and I think that's a place where the added dollars to our practice has changed how we care for patients the quality of care we give the patients and also it's very important to have that psychiatrist in your building it doesn't scare the heck out of those patients to go off to somebody they don't know because it's already a vulnerable group psychologically and they don't have to go to a new building you can introduce them to them so that's been very helpful we also were able to increase the hours for our certified diabetic educator somebody mentioned slash nutritionist for patients whose insurance don't cover if you have Medicare and you're overweight Medicare doesn't pay for overweight but Medicare will pay if you have a high cholesterol or diabetes or renal failure but there's a lot of people who are into those things so we can now have her see those patients and assist us with them in-house and that's changed the way we deliver care as well the third project of ours was to keep our laboratory in-house because we feel it's more efficient quicker more convenient for patients but also costs a lot less than getting your blood drawn in your laboratory work done at the hospital so this new pilot program of which we're apart has resulted in at least three areas where we feel we provide better care hopefully keep people out of the hospital and I think it's going to take a few years of results here to know that for sure and we have a new care coordinator through this program as well we've documented about five people since Christmas who ended up not in the hospital because we had somebody to coordinate whatever care they needed and it may be different kinds one other thing I would say is I think this pilot subgroup of the all-payer problem or all-payer plan has enabled us to recruit a new physician and now that's something in independent primary care is extremely difficult so I think for my ultimate goal that seems to have been successful we'll find out before too long somebody else has to match for a program and that sort of thing can you explain why it helped you recruit what was it about the pilot program that helped you recruit? Well, money we could offer it there were some providers out there what was the scope on doing and that was actually an attraction to you well, loan replanment plans travel assistance, signing bonus when I practiced you had to pay to join the practice when I started now it's long ways from that so I would say this especially the subset of the all-payer model that is this pilot we've been very pleased with it doesn't fit for every practice there are practices a capitated model won't work as well for if you have a demographic group that goes to the doctor six or seven or eight times a year then this capitated model may not be as good for you financially if you have a practice wherein the average patient goes to the doctor three or four times a year and the capitation is appropriate then it will be successful so I don't think it's for everybody yet but so far it's been good for us we have an overdosed on the Kool-Aid but it has tasted pretty good so far we'll see how next year does off to Steve I was going to actually ask a quick question about follow up my next question is going to be about the all-payer model the ACL model has increased its emphasis on integrated care we've heard a lot of stories about the care integration I'm wondering if you all can speak to whether what would you attribute the increased focus on care management is it the fact that there's more funding now population health payments for care coordinators is it the tools that are available the care navigator that's allowing different providers across the care community to share information is it the training and consultation that comes with contributing lives to care what would you attribute the increased care management to I'll start since I have the mic I actually think it's all those things I think it's a blend of all these things they're different so every person on this panel that went into medicine for whatever reason their goal is to keep their community and their patients as healthy and well as possible but for most all of our careers we were paid to care sick people and so for the primary care docs on this panel, literally if someone called you and you knew they had a UTI and you knew you could call in a prescription and make them better you lost revenue for that so this model helps get around things like that at just a micro level this model is funding our community partners to do the work they need to do and have been starved for funding for many years for a wide variety of reasons and as you move towards a wellness model it suddenly makes sense to invest upstream because you don't need to see one more patient in the ED you don't need to have one more admission I mean for most of our careers a readmission was bad for the patient but good for the hospital for every life that's covered under the ACO a readmission is one of the worst things that could happen you know you have to get people so at UVM Health Network we've made a major investment in a care transition team we have a doctor whose full-time job mostly is making sure that when people come in the hospital we know all the information from Thomas Chitton and all the detail of their meds and all that and we send them back to Thomas Chitton and we make sure there's a seamless transition if they're going to the nursing home we've added a new leader who does our care coordination both inpatient, social work and outpatient those transitions of care are expensive now if you get it wrong so I would tell you there's a major shift in now it suddenly is financially viable to keep your community and your patients as well as possible with the care coordinators especially care navigator we're still kind of lukewarm on that partly because of a lot of what would go into care navigator from the community we have embedded in our office so it hasn't been as beneficial and it's a little unwieldy yet but one of the big changes I would address again being old is that several years ago almost all the hospitals in the state switched it inpatient care being cared for by hospitalists and one of the biggest one of the most common times to make errors in patient care is when you switch providers whether it's a nursing provider, physician PA, whoever and that became a real problem with the advent of hospitals for a while some of us were in a hospital a lot anyway but I think the care coordinators that we have hired in our office through this program they call every patient when they go out of the hospital and we've got everything right there and that's a huge help discharge summaries they don't always have everything in them you need and they don't always get there but the care coordinator for transition out of the hospital has been extremely beneficial and then the care coordinator who switched for us carenates with nursing homes and now we have a lot of short-term rehab for they're in a nursing home or wherever for four weeks, six weeks has been very helpful in that as well so with the increased fragmentation of hospital versus community versus outpatient care the care coordination has helped a lot I can't put a dollar amount on it but we can name people that didn't get hospitalized because of it you want that? I just wanted to add in speaking to the same verse Segway is that also our falls prevention for EMS is very involved so when they go to a home where there's a fall and there's going to be a transport they always follow up with me to say this is what we found out in the community would you please follow up and coordinate or they're taking care of their PCP where they need to be and that's worked I know at least in four cases one in particular we just dealt with this past week where I got a phone call from the senior center to say did you know the ambulance is over at one of your patients homes in the complex so I went right over and there's the ambulance and the deputy chief of the EMS who's in charge of falls prevention and she's like oh my gosh she said this is perfect timing and so we were able just to coordinate right there on the spot next steps for this patient which worked rather well so I think it's just an added piece once again that the more community involvement you have the better off your patient is going to be I think one of the things that's helped has been the emphasis on training and looking at best practices it started with the blueprint with looking at a care coordination learning collaborative and then continued with one care so that we're getting tools and education and building capacity while we're doing this work because you're training a new workforce and you're working with people that are doing new things and so workforce is an area that's of concern for all of us and we need to help people be prepared and last in their jobs I mean frankly we've had people that have started the positions it wasn't a match we need to help build a new workforce that can do this work and really help people and I think providing that training and the best practice tools has been able to help us make that transition I agree with what has been said about the fact that it is the additional funding both through the blueprint and through one care that has allowed Porter in our practices to employ dieticians mental health providers therapists, care coordinators and before it was we couldn't justify it in a fee-for-service world there's just no money for that I think we do need to think about our workforce we don't have enough social workers we don't have enough mental health providers in our state we don't have people going into those fields and we need more of them so we need to focus on that education I think there's still a lag I'm concerned about educating our providers and our health care force about this new style of practicing medicine I think a lot of us are on board but there's still a lag in an understanding I think my perspective being a primary care provider and also the chief medical officer at the hospital lets me see a little bit into how some people are still really focused on we need the ER to be humming we need the main floor to be full even Dr. Niffen as much as I love him he's like oh the main floor isn't full and I said great we don't want people in there and he's like but then how do we get paid so it's just this changeover that I think is we're right in the middle of it and I believe it is the right thing to do I think that care coordination tends to happen fairly naturally when you put people who care about that passionately in the right places and meeting patients where they're at and this funding model has really supported us in doing that with money to higher care coordinators and it's really I think that healthcare has been sort of late to the party on this we know that designated agencies for mental health, home health agencies SAASH Agewell, those are folks who have been doing really great care coordination but often when they would call the primary care offices their mindset and sort of the mindset of the folks in the primary care office often didn't meet up and so to have someone who answers the phone in primary care and says how can I help with whatever messy, probably not medical problem is going on right now has really been key and then those relationships develop naturally and then continue to get stronger as we work together mutually with patients and finding it really satisfying I think anytime we think that there is an electronic fix for a problem that we have we're often a bit disappointed so while there's been a lot of excitement around Epic and Care Navigator is a good tool it really is only one part of what we're doing it's really about the people and the relationships that we're developing I think that some of the this transition to more care coordination between acute and post-acute, all the community providers is really because of our focus on the triple aim, the triple aim of healthcare is to improve the patient experience, improve health outcomes and reduce costs we know we can't do that just by admitting people to the hospital, by letting people get sick so there's really been and this is why I was saying before how much I'm enjoying my job and home health right now is because there's really this recognition in Vermont and really is starting to be nationwide also that hospitals aren't going to do it on their own we all need to work on this together so that means we've got to start doing a better job of communicating with one another one of the really wonderful things that I'm looking forward to is the V&A of Chittenden and Grand Isle counties we've renamed ourselves the UVM Health Network Home Health and Hospice because we became part of the network in January 2018 so that means in another couple of years we're also going to be able to be on the Epic Medical Record System so to actually have home health staff and the hospital and many of the primary physicians the primary office is being able to all be sharing the same medical records so it's not just that our records could talk to each other we'll be sharing the same medical records so then it just becomes so much more transparent I'm really looking forward to that and I've got to say I grew up in Vermont in the Northeast Kingdom and we love to tell stories in the Northeast Kingdom and so before I pass the microphone to Dr. Fontaine of course is so focused on wellness I want to say that the focus on wellness has just given me a whole new opportunity for stories so one of them is that my mother started jogging when she was 80 now we don't know where the hell she is so in my model care coordinator I don't need it they wouldn't exist now I'm just saying that so I'm going to pass it I don't have the chance to work so much with care coordinator because where I work into the lifestyle I don't have the chance to work with this team however with the implementation of having a coach that would be working in primary care then I would become a little more in association with my partner now I didn't see anything earlier you know obviously everybody has recognized my accent I'm a French Canadian my father was a physician and I was in the area where the universal model was born when I was eight year old not knowing what I was doing or seeing people bringing home eggs or maple syrup which was pretty interesting but eventually having the card that allowed them to be treated and as much as we can say against the Canadian model everybody is treated there without having to you know to go through what we have to do in our current system so I think that Vermont is ahead of the game and I'm very interested into the effort that we are doing here in the all-payer model so I have two comments and to answer the question what are my thoughts in terms of why integration and care coordination has evolved I agree to the point that everyone has made but I really feel that making primary care practices recognize NCQA patient-centered medical home when you look back to the advent of all of that and I have been in two practices that have been patient-centered medical homes and I've worked on that whole recognition process that is the hallmark of a patient-centered medical home and care coordination is at the center of it and so to be a robust patient-centered medical home you must have a robust care coordination and I feel like that's where everything began I previously practiced in New York State for 23 years before I came to Vermont and so I want to kind of bring back to the point that Dr. Haddock made a little while ago about the necessity of primary care being the foundation of all of this and without primary care without folks that want to go into primary care physicians nationwide we're having a shortage we're having everywhere problems with recruitment and retention we need to make primary care desirable why am I here in Vermont because I got to a point in my career I've been practicing for 25 years I got a point in my career where healthcare really reached a dark place and I saw what was happening in Vermont and it piqued my interest I came up here I spoke to folks up here and I was like you know what this is what I want to be a part of and everyone who's been working so hard here because that's what brought me here and if we can really as we're trying to for those of us that are in the recruitment and positions here if this is what we share with our medical students that healthcare can make changes because you go into primary care and if we can show what we can do and where we can go then I think not just as a state but as a nation in a much better place Thank you all for coming I question about some of the challenges of implementing this kind of community based model so one of the things that we hear on the board is I wouldn't say really a criticism it's more just a concern that when you look at ACO evidence across the country there seems to be a quicker return on investment in programs that are very top down network restrictive and really operated more like an insurance model in Vermont we've chosen not to go that route first with the blueprint and now with having one care work collaboratively and really integrated with the blueprint so I wonder if you could speak to what you see as either some of the challenges of creating this really community based approach as opposed to what I would call an insurance model or directed approach or I think you've highlighted some of the benefits of that in terms of really integrating the community but I just wanted to put that out there because that is an issue that we hear and a concern about maybe the road that we've chosen in terms of a community based approach either maybe less effective or maybe harder to implement or maybe take more time I don't know if you have different hospitals and different health service areas are pretty dramatically different one of the things that my experience with one care has been that there is a lot of guidance a lot of training opportunities a lot of presentation of best practices and then very intensive support as we develop our programs but thinking of the needs of Porter hospital which is a 25 bed critical access hospital as compared to just an hour north one size fits all solution would never work I do think it has been a little bit slow in developing our well I don't know if slow is the right word because maybe it's the right pace but it has taken time to develop our processes again very kind of step by step with one care and I feel like that has really allowed us to put in a plan that doesn't just feel like the flavor of the month and here's a new checkbox and we're going to focus on it for three months and then we all forget about it and then we're going to focus on the testing change that we're creating I think one care has given us the financial oomph to get over this initial hump of it's not going to be an immediate return on our investment but we can already see really huge changes in our utilization patterns both anecdotally as well as with the big data that we're able to get using care navigator and the claims based data so yes slower but also really in health service areas for those of you who remember we tried the top down thing with chp slash Kaiser and literally in Wilson Vermont we had to call Oakland California if we wanted to send our parking lot more than once a day now that's a little bit hyperbole but that's the kind of way it was run we were supposed to see 3.2 patients per hour you worked 4 or 4.5 sessions a week you couldn't work weekends none of the nurses could work overtime it was we were making widgets and I think from my own point of view and I'm independent to a fault that if it's done from the bottom up sort of the bottom up it'll be more successful and more customized to the needs of the individual patient populations that practices that's our experience to build on that one of the conditions of the all-payer model is that providers voluntary join and when the providers join they bring in the lives and the goal over 5 years is to get 70% of our monitors in this model and 90% of Medicare recipients and while it's probably a little more painful to do it by the voluntary method that's what's sustainable on a panel like this that I'll want to talk about how great it is, how it's changing primary care how they can recruit new doctors here is really what's going to make this stay and last in Vermont I would tell you the hard part is that if we could flip the switch today and be to full capitation we'd be much better off because then all these sounds would completely align we're living in this world right now where 20% to 30% of our lives are capitated which in sense you do care one way and the other part is fee for service this does give our hospitals that very high fixed costs adjustment time to get to right sizing but it's very painful going through the slow changes that happen when you're half in one model half in the other is what I would say just to build on that one of the things that I've we've struggled with is the fact that in care navigator you only have the attributed lives but we take care of a full population so we want to get to the place where all of the patients are we are able to talk with all of our partners so right now we have some of our partners at the table but we actually work with the schools who aren't really at the one care table yet but we know they need to be because we're working with them for the pediatric population so there is struggles and challenges in a system that's evolving but I believe it's evolving in the right way and it can't happen overnight and I'll just piggyback on what Joldus had to say it is challenging when we get the list to know that our partners are working with us economic services DCF the schools but they're not actually in the system so that's a hiccup there that we need to get over speed bump I think another factor contributing to the slowness of doing this and I do think we're doing it the right way for us has been a lack of data analytics and I think as we move forward with all at least the UVM network and others around the state being on Epic and being able to share our data and manage our data and analyze our data together we can drive this and hopefully the speed will pick up after we're better able to do that and from the home health point of view I would echo what Steve said we really live with a foot at each canoe because we are for home health we're not capitated we're still in a fee service program for reimbursement so we're following all the very strict Medicare rules to be able to be reimbursed for clients who are Medicare eligible for Medicaid we follow a different set of rules and there are skilled care rules and long-term care rules for health insurance companies it's a little different again so it takes we end up spending more money on administrative overhead than we want to because we have to you know be compliant with all of these different programs where we really feel like if we were in a truly capitated system we'd be able to do the right care for the right person in the right place talk to the right people and it would be so much easier but so it is that you know we're able to do that long-term care program I described because one care is supporting that with extra dollars but so we would there's so many other things we would love to do and we are starting to do more pilots I do want to say that there's a part of the one care is a waiver for home health agencies to be able to do home visits to people who have had a hospitalization even if they are not homebound homebound is one of the Medicare criteria a person has to be homebound and need skilled care to be eligible for home care services but this new waiver through one care when we're just experimenting we're just beginning it now with one practice Colchester family practice in Chittenden County and we'll be able to see people because when you've had an acute care an acute stay even if you're able to get out and about or you're not requiring like dressing changes or some particular skilled care people still have their medications confusion they might not be able to get their medications or have transportation there might be home safety issues there just so many things that we'll be able to address and it's just one or two visits but we really believe it's going to help decrease hospitalizations of patients who've had a hospital stay so in my little model of lifestyle I always say that I want to approach a village to health so for me in order to be able to do that I need to absolutely be in a capitated environment because in FIFA service it doesn't exist I would have not been able to survive in the FIFA service model I've explored a lot of people do it cash base and was thinking about my own model I said well the people that really need my help they don't have the money to come cash base so the only way for me to work that way is to have a capitated environment and if it was none of my hospital that believe into putting money in this innovation I wouldn't be here to talk so it's very important that we progress in this model I just want to make one comment I think one of the challenges is that we're trying to service patients that geographically are far from where we can provide services to and and when you're thinking of trying to provide services to perhaps like one or two families you know how do you justify sending a team out where it could be like an all day affair and to service that and often these are families that technologically and we can't provide services such as telemedicine so sure I think I'll direct this one directly to Steve and others ask others to join in on the conversation but one of the challenges on being successful and moving away to value based rather than fee for service is getting a large enough panel and a large enough pool and one of the struggles we've seen in Vermont is getting take up by the private commercial market and I know that UVM has tried to be a leader by putting their own employees in that and I was wondering what you would say to others who are considering a decision to take this leap of faith and try a different approach what would the conversation look like Steve? Well first off I think there's two big parts to that. Number one it's absolutely one care and providers have to show that we're going to add value we're going to have to add value to whatever piece of that premium so the way that model would work is most of these plans are administrated by I'm sure I think Blue Cross or MVP and they're getting a premium right now to administer the plan and what you're asking for is to have a little bit of that premium and with those dollars you're going to keep that panel either healthier they're going to be showing at work less absenteeism they're going to have overall less healthcare costs so we piloted at the medical center last year how that could work to build on that and I can tell you right now that within one care we're spending a lot of time right now figuring out how much of that premium is the right amount and what are we going to do with it to help keep people so when a large self-insured population comes in like the UVM health network or like the city of Burlington or national life what are they going to get that's different that adds value to that premiums and I would tell you those are things so like low absenteeism healthier population low overall healthcare costs the delivery system firmly believes that those dollars flowing to your providers and their care teams around them is where we can make a big difference because all the stuff you're hearing here I think we can bring out to those employers in a way that's different than is happening right now one thing I would expand that to is I would like to see I don't know if anybody can do it but all self-employed groups benefit from the blueprint they don't pay into it and somehow or other I don't know how you can require that but if you can demonstrate a benefit from the all-payer plan you can certainly demonstrate a benefit from the blueprint and the embedded services or extra services we all provide that employees of self-insured companies are benefiting from but not paying into so I think that could be expanded from all-payer model to the blueprint as well I'll just finish with at the medical center we have some data that shows it was a good model last year we have to do more we're not really ready to roll that out but it was successful last year and one care is very interested in growing this and figuring out exactly the pieces is the stuff we're spending lots of time on right now I'm struck today by the contrast between what we're talking about this morning and what we will be talking about this afternoon this morning the affirmation of one care and you folks on the ground achieving what you're achieving is heartwarming and I'm glad to see it this afternoon we will be in the process of reviewing the QHP benchmark plans and I'm struck by the contrast that for example speaking of pre-diabetes that you can under the benchmark plan go get a preventive health checkup and be told that you're pre-diabetic and then the next step is you've got to kind of hop through these hoops of deductibles and copays to get to the only remedy that they provide which is metaformin as I understand it I'm not a clinician but I'm being told this and so the benefit that works the best which is nutrition and fitness counseling isn't even on the menu so there's a very wide gap here in my observation and I just wanted to make that observation that we are still worlds apart and we've got to find ways on the board to make decisions to move people in your direction and I think the QHP population is just one platform upon which we can do that and if you have any suggestions in that regard I'd love to hear them One of the things that struck me while you were talking was we haven't talked about the self-management programs and I think it's really important for us to be able to highlight that, that's something that blueprint started and so that we have healthier living workshops, we have pre-diabetes workshops, we have chronic pain workshops, we have the RAP programs for mental health, you know it's frustrating when a patient spends this amount of time in the doctors and the doctors and providers tell them you need to do this but you got to walk the journey and be able to learn how to do that and build skill and capacity and so I think that using this peer model and in a best practice approach where you have actually people that have the chronic diseases themselves that are teaching their peers and have support with a curriculum that is shown to work to actually build capacity skills within the people themselves actually be, it's able to change behavior and we've that's like I said it started with the blueprint and continuing in support with one care in an expectation that we actually work with groups of people to teach them and help build their capacity and they helped each other so thank you for bringing that up respond to that a bit I mean I think the blueprint is a wonderful network and I'm looking at the self-management workshops and in terms of pre-diabetes when the number of people that start their workshops and finish it's a very small number I think in their 2017 annual report it was 184 people whereas the health department will say there's a minimum of 27,000 people in Bermont that are pre-diabetic I'm looking for paths to kind of encourage the flow of funds into the blueprint to expand their efforts in terms of their workshops and maybe align with the CDC program for pre-diabetes that seems to be well received and evidence based so actually the CDC and evidence based model was brought in for an article of the New England Journal of Medicine that had demonstrated that the lifestyle modification works better than metformin after a period of time so one of the biggest thing that we encounter with this model also is that we are as a health system and physician responsible of the health of our patient but where is their responsibility how do we see to tell an individual that you brought yourself to this level I just mentioned the importance of lifestyle and they're not willing to make the change to what extent do we have to take the responsibility so I certainly take a lot of time to educate with the coaching before we send them to make sure and you have to be there and talk to them all the time so the CHIP program which is a little bit of a difference of the diabetes prevention program they stick with us so we are constantly and coach them in between sessions to make sure that they continue working with us so there are these organized self management programs but there's also self management where you're engaging the patient in your office and with the advent of health coaching and getting certified health coaches and we're really excited in primary care up in St. Albans because we just hire two certified health coaches to be our partners to really because what we find and what I have personally found is that patients respond better to services when you have them embedded in the practice when they don't have to take extra time out of their day to go to a program and things like that so we're going to see where this goes but you know for our pre-diabetics our patients that don't have any chronic medical problems but are perhaps overweight and all these services that are not covered by insurances so we have these health coaches embedded in our practice and we as the physicians will be segueing meet our health coach, see if they can work with you to identify what the barriers are that you're not able to achieve the goals that you want and so obviously there has to be some motivation on part of the patient but I think this is going to be a great asset and I'm really looking forward to see where we are a year from now. Okay, wonderful. I wanted to first of all thank you for all of that and for all the insightful, inspiring and optimistic about the direction and the whole idea of leading these efforts. I wanted to make sure that we open about public comment so just Susan, I know you have that wireless mic so if you want to help facilitate any kind of public comment, folks have questions or comments this is a good time to ask those. Actually if we could because legislators are here if we could give them the opportunity first if they have any questions or comments because I know that they've got a limited time schedule. They're surprisingly quiet. Legislators? Oh and if you could say your name, who you represent and direct any comments or questions through the chair of the board. Thank you, Mr. Chairman. I'm Jill Olson, I'm the executive director for the V&As of Vermont we represent Vermont's Home Health and Hospice Agencies and I just wanted to I guess through you thank the panel for this morning. I just wanted to connect one policy dot that I don't think I've heard touched on but not fully referenced which is those delivery system reform dollars that are actually looking to be cut right now in our state appropriation and what I'm concerned about is that we haven't really fully invested in this reform process so that we can make that leap from where we are now to the more capitated model. I think Dr. Leffler touched on that problem where the system isn't yet fully capitated. So what that means is something like the longitudinal care program that Judy talked about that is really successful and I think we should be spreading all over the state and we're going to work to do that. It's a little bit hard to get programs like that off the ground to have dollars to pay for the first try and in fact when Judy started that program it was through a grant so she was able to demonstrate the value of it through a grant to then make the leap to actually embedding it as a program so without one care having some of that flexibility to have some dollars to make investments to show these kind of interventions can work I think we're going to continue to struggle with moving as fast as we'd like to move. Thank you. I'm Kim Fitzgerald. I'm the CEO for Cathedral Square and we are the state-wide administrators for the SASH program and I did want to make a comment today obviously in addition to what all the panelists said because I think SASH is a perfect example of the capitated rate and we have the flexibility so I did want to just talk about our recent results. We've obviously been very successful under the blueprint for health but for the majority of our staff on the ground through one care so we had our latest results in August of this past summer and it again is showing that we're reducing Medicare expenditures by over $1,200 per person per year. In addition these evaluations went a little bit further to demonstrate that we are reducing Medicare ER expenditures as well as specialist visits as well as dually eligible participants are reducing their Medicare expenditures as well and so we're obviously hitting all of the aims of the all-payer model through those results and so we continue to hope to do more of that. In addition I want to call out a mental health pilot that one care funded this past year in collaboration with Howard Center and with SASH and we embedded a mental health clinician hired by Howard in two housing locations where people live and within the first year found immediate positive results including a lot of male participation which is usually the hardest cohort to reach as well as we found that the able to see the person quickly usually same day which in crisis situations can absolutely deescalate a situation we also found a lot of group programming so again that population based approach is really successful and efficient and lastly there we also have prevented evictions as a result of having the clinician right there which then of course prevents homelessness. So I also have to since I have the mic and have the opportunity I do want to address the legislators as well because you may have heard that the governor's budget has a huge cut to SASH in the budgets 55% are almost $541,000 and that would be devastating to the program would really wipe it out and hurt it over the long haul of course and one of the claims is that one care should just pick it up which is not something they're able to just do so I would just advocate for the legislators to support full funding of SASH and the Dale budget and to know that we are also as many other community service partners we are reducing those that are in nursing homes we're preventing or delaying admissions to nursing home which is saving the state of Vermont a lot of money so thank you. Hi just your name and where you're from Hi my name is Mark Tully I came up here from Brattleboro today to be in solidarity with disability awareness day until I found out this corporate advertisement was happening I want to object to the funneling of the people's money to a for-profit corporation I want to object to the privatization of Vermont's healthcare system okay I'm glad all these outcomes sound fabulous every single one of them is because a corporation is pumping money into this pilot program coordination of care training of staff making life easier for primary care providers none of that requires corporate privatization why it's happening now is one this board is not funneling the people's money pilot programs for public solutions to this thing you're funneling to a for-profit corporation and every single one of you have been talking about outcomes it's money this corporation is pumped into your practice to hire staff trainers it's all like how much money or how healthcare will be rationed once this pilot program is over once all of this cash to make a big shiny pilot program is over is completely uncertain and I also you know I've heard from and about independent providers who choose who would like to stay independent there's nobody on this board this is not a report from the field there are not a variety of provider experiences as there are out there this is I don't I don't doubt your credentials or the veracity of your stories that thank you for your service you all seem fabulous people there's not a single provider who's being hurt by this and there are providers being hurt by this and I find the exuberant advocacy coming from some members of the board to be tasteful an abrogation of your duty to be a neutral arbiter of the business before you thank you any of the legislators before you have to go or do you have a comment oh that's okay but I just wanted to check in okay let me go over here and then I'll come back this is a hard job it's good exercise it is hi I'm Deb Richter I'm a practicing family physician in an independent practice that is not involved with the all payer model and I must say that you've made the wonderful case that primary care is essential and I don't think anyone would disagree with that I think we also you're alluding to the social determinants of health so my problem with all of this and I see this every single day is the fact that it's supposed to be patient centered yet we've left out a major piece the fact that many of my patients have rising co-pays and deductibles and are now dropping out of care including addiction care by the way and going back to the street because they're suddenly going from Medicaid to private insurance which has huge deductibles for them and they begin to say well gee I can get this stuff cheap on the street and I don't have to pay for your services so it seems to me that until this is the cart before the horse you are all laudable and it's wonderful the efforts that you are making and I know you have the best of intentions but until we get everyone in the system into primary care they're stopping themselves at the door if people they're supposed to be seeing me I diabetics four times a year I'm seeing them once a year sometimes because they can't afford the co-pays and the deductibles I'm seeing in the house that I'm hoping that Chairman Lippert will bring up and I'm hoping it will pass the legislature H-129 universal primary care which would publicly fund primary care for all Vermonters including outpatient mental health and substance abuse services I don't see how we could any of us we've made the case that primary care is essential how we could not be in favor and have this be the first thing we want primary care doctors to want to stay in primary care because we have a problem a lot of us are retiring a lot of us I think a third of the population of the primary care our doctor had its age my age right we're going to retire in the next few years so if we want people you have to make sure that your patients all have the same health care instead of us you know some of the private insurance getting more services than somebody with Medicaid or whatever depending on the service so I think that we really need to discuss that and that needs to be something and I hope the legislators have heard me I know I know I have to talk loud but anyway thank you I will work my way over here your name and where you're from my name is Julie Tessler I work at Vermont Care Partners representing designated and specialized service agencies I thought these were great presentations and of course I listen for mental health but it comes up a lot many of the complex cases are people with mental health conditions and the care coordination is a collaborative effort and it's going very well but one of our challenges is our workforce and I know there's a challenge with primary care and nursing workforce too but especially master's level clinicians that's a critical service so we get referrals we're doing care management but we have vacant positions it's harder for us to really meet people's needs when you've looked at workforce so I hope you keep that on the radar screen that we need to look at investing in Vermont's workforce and designated and specialized service agencies for us it's a much of it is around the rates and what we can pay for our staff and attracting those staff so finding a balance and how those resources are allocated and making those investments will really make a difference in helping us provide those community supports and keeping people well I just want to make sure I get back over here and let me do the legislators first because they are on a timeline Thank you for your presentation and Mari Cortes I'm a registered nurse at UVM Medical Center and representative from Lincoln Bristol Monkton in Starksboro and on the house health care committee I have a question about quality measures and how are you what data are you using to measure your progress or opportunities for progress what benchmarks in one chart I saw it looked like in 2017 the Medicaid benchmarks there were actually no benchmarks for specific categories like 30 day follow up for substance use or mental health and yet the progress was scored at the highest level even though there was no benchmark to compare it to but those were just Medicaid benchmarks do you use other benchmarks do you have data for us later than 2017 I'm looking at Steve because I'm thinking you might have the So there's something called the ACO33 which are measures you're talking about and they're a mixture of reporting measures on some of them early on to get credit for just being able to report them being able to gather them which is not always easy going out to our primary care offices and pulling that data in and some of them are outcome measures and they roll up to an overall score and there's measures for Medicaid Medicare and commercial and depending on the data lag there's different times the data comes in we can report them at different rates but I know that for 2017 all the Medicaid data is finished and you must be reconning some of those were just for the first year strict reporting measures to see how hard was it to report how much of a burden is it on our doctors to gather that information are we getting what we want out of it and then they're supposed to change over time we're supposed to adjust them to make sure we're gathering ultimately what you want is good outcome measures we want them to because that's really how you can show over time that the third part of this model is of Rwanda's Healthier over the next five years in this program and there are a number of measures that talk about access to primary care disease burden for the state of Vermont for Vermonters mental health visits after an ER stop those kind of things are critical so we do have data and one care could definitely come and give you a presentation but the data that we have for each payer is at different time frames because it's when they get the data back hope that answers yeah it's just the part between getting a positive score for reporting versus an actual outcome I think might be unclear at least to the public so we could come back and show you stuff on that thank you again your name and where you're from hi my name is Ethan Park I'm just representing myself I hope my question here is not too tangential but I learned that late last year CMS and the office of the inspector general granted the Vermont Medicare ACO initiative and they all payer model waivers from certain federal fraud and abuse laws while I understand the goal of building these systems of integrated care I think that's a very laudable goal it just kind of raises a red flag for me the fact that the federal government would allow an ACO to regard disregard laws that were put in place to protect patients and save the public healthcare dollars the waivers that Vermont got involved the physician self referral law the federal anti kickback law and something that's called the patient engagement incentive law so my questions are from a patient's perspective how can I be assured that a referral is being made and the procedure is being recommended that is in my best medical interest as a patient and not merely in the best financial interest of the ACO how can I be assured that my doctor or clinic or the ACO itself is not receiving a kickback when I choose a specialist within the ACO how can I be assured that a special service or item of care given to me is not meant to coerce me into staying within the ACO network I have brought an abuse statutes into place for a reason shortly after the enactment of Medicare and Medicaid they are there to prioritize care over profits and to save the taxpayers money I know that these waivers have been issued to ACOs all across the country not just Vermont but it is arguable in my opinion whether ACOs should be exempt from these laws why not focus on full disclosure to patients transparency of financial relationships between providers and between providers and payers and coordination of care that is a matter of public policy totally free of opaque preferential networks provider paybacks and beneficiary inducements thank you so there's a lot of questions there and not sure if we can answer all of them but maybe and I also want to recognize the audience as well not to put her on the spot healthcare reform in Vermont and participated in the negotiations on this waiver but I think I can turn this over to Mike Barber or general counsel actually Mr. Barber covered these waivers are not unique to Vermont they were issued to Vermont because we have kind of a unique program Medicare next generation program for the shared savings program they basically enable the kinds of arrangements that ACO needs to have to do these things otherwise federal law would prohibit a lot of this and I would also add as part of the oversight of the Green Mountain Care Board for the accountable care organization One Care Vermont the very transparent nature of our budget process and in depth nature as I think many on our staff and folks at the ACO could attest to and I'll turn it over to Dr. Lefler so it's a great question and what I would say is that the reason that these were put into federal statute is because at times people were abusing the system and were self referring the easiest example I can give you of why this is a good thing to have these time and a hour doctor by training and for the vast most of my career we would have someone come in who very clearly needed to be admitted to a nursing home but in the past because some doctors owned nursing homes and would self refer patients to those nursing homes the federal government made a waiver that you couldn't send someone from an ED directly to a nursing home I had to admit them to the hospital for three days there was cost to the patient to do that it wasn't good for the patient for their family for the hospital for anyone that was put in place because there were some bad actors out there we have a waiver now that lets us send people directly from the emergency room when appropriate to a nursing home which we don't own it's better for the patient it's better for the system because they're not using up an inpatient bed I think I saw that Porter sent more than 30 from their ED now directly to nursing homes that is good for everyone so I will also tell you that every time one of these waivers comes up in front of the one care board we have to we have a lawyer that sits with us and make sure that we are fully compliant with the spirit of what's supposed to be happening and no one is personally benefiting in any way from following these waivers except the patients I'm going to just make my way around here I saw a couple of hands in the back Hi, I'm Richard Slesky and I'm now retired I was the director of payment reform working with the Green Mountain Care Board and helping in what way I could to help develop some of the programs that we have today and I just want to say that it's really gratifying to hear all of you speak about the ACO the progress that's being made when we were developing this program there was a great deal of concern about the consolidation of services through one ACO and whether that would tend to pull money away from community-based services and consolidate it into the hospitals and not be distributed in the ways that you've all demonstrated is actually happening and it's great to hear some of you say this is the best time I've ever had in healthcare and this is on a community level and my mantra when I was talking about this was always to say how we get paid matters and I think you know if we pay fee for service you're going to see more volume more services more things being done probably some of which are unnecessary I think it's certainly been proven to be the case if you move toward value-based payments you're going to see a shift in motivation to keep people healthy and I think that's what you all are talking about today and it's nice to see that that's actually happening in Vermont I'd also say in terms of just one quick comment I know those of you who know me know I'm full of stories so I won't tell a lot but one thing you know when we talk about the ACO being a for-profit entity you have to distinguish between a for-profit corporation that actually distributes its profits to shareholders or other corporate owners as opposed to a corporation all of the hospitals in Vermont are not for-profit and I believe all the agencies associated for the most part with the ACO are not for-profit so this is an organization that if it does generate margin it will reinvest that margin in services it's not sending money to individuals or to shareholders and that's a big difference and I think you need to keep that in mind when you make that argument so I just want to congratulate you all it sounds like it's going well I hope the board and the legislature will continue to support these efforts it is going to require investment continuing support continuing commitment to make this work and I just hope you all will continue that support thank you thank you one more question Chair is that okay? can we do one more? do you understand that? Dale Hackett one I always love the spirit of Vermonters they're very colorful they're always participating and they're exceptional and how they go back and forth and work together in a sense as a team my question much of the data that the ACL has I have a question around do they ever doubt what the data is telling them because it's more inductive in nature and therefore can lead to false conclusions I'm not invalidating the value of data I'm only questioning how it gets interpreted and how careful we are in interpreting the data the other one would be I didn't hear much about workforce issues if they're actually struggling to get the people in order to do the work and then someone suggested that the coordination of care depends more on the skill building and the patient if I heard it correctly in order for the primary care delivery to really be effective and perhaps I'm paraphrasing or I thought I heard something along that line suggested I'm going to leave it at that because I see one head shaking yes another one shaking no and so I think I should stop right there once again you've turned your duty of asking the best questions and comments so Chair Mullen so I wasn't watching the panel so I didn't know who was shaking but whoever was doing this you have a comment to a couple of Dale's questions I had been shaking my head yes in that helping people to develop skills I think is often a first step in helping folks to be more in charge of their own health care so while we may have a goal of reducing someone's you know having their blood sugars under better control or that they will stop going to the ER and start going to primary care really we have to go to people and say what do you need and how can we help you in developing the skills that you need to accomplish the goals that you've identified and any of our goals around you know again utilization or management of chronic conditions those are all really secondary and important and work with them on developing those skills first so that was the yes shaking I don't know if there was other shaking that needs a microphone so while the panel is looking around and you want to speak to that I want to follow up on a point that Dale made and that is the workforce and what we continually hear in the budget process is that hospitals are paying twice as much to employ a traveler or a localman they would have a member of their team and we also hear some comments that the quality may not be as good because that person isn't as familiar with the equipment in a given hospital or knowing all the services that are available in the community and so I try to label it as the number one issue facing healthcare I don't know if anybody on the panel wants to do this but with all the legislators in the room there's so much that needs to be done in workforce if we don't get started soon there's going to be a crisis and then we'll be reacting to something that we should have reacted two years ago I'd like to make just a couple of comments about the nursing workforce there's definitely a shortage in Vermont and there's a shortage in the nation and I had the opportunity to be talking to a group of our personal care attendants because at Home Health we also have entry level positions we have about 200 personal care attendants who do long term care services and I was at a meeting with them just to ask them what were the barriers that prevented them from doing the kind of care they wanted how we could support them and several of them said geez they wanted to go on to be nurses and there's no way they could do it because they can't afford nursing school and they have to many of them were single women with children so they needed to work full time at $11, $12 an hour and there's no way they could go to nursing school so I think there's an opportunity in Vermont I think there are people who are recognizing what good work nursing is and other health professions and they want to do it but in Vermont I mean many of the things we've talked about whether it's poor nutrition lifestyle habits and all of that a lot of this needs to be addressed by Vermont as a system change I really believe in the responsibility of individuals and people needing to take charge of their own health but a lot of our systems don't whether it's the availability of junk food and there's a lot of pain paths that we as a state there's a lot we could do to help promote good health but anyway I digress so the workforce issue I really believe that we need to look at other ways we can fund people to be able to get nursing education and then they would guarantee they would stay and work in Vermont for a certain number of years one of the problems for nursing educational institutions most have long waiting lists for people to get in so there are both system issues that I'd like to see us address in terms of the workforce crisis that we really are seeing amongst primary care physicians I previously was at a medical school as faculty and when you have a graduating class and you only have maybe one student going into family medicine we have a crisis as someone alluded to and a lot of folks retiring and with the cost of medical school education what I hear from the students that I worked with was like how can I go into primary care when they have half a million dollars in medical student loans and the salaries coming out of school won't compensate the loans and having to support themselves so I really don't have an answer but I think if we want to change in terms of getting more students who may want to go into primary care but are thinking financially how do I do this I think we need to take a look at the bigger picture at the cost of medical school education I would just echo what they said about nurses we can't hire a nurse we run an ad in every place possible for eight months and you might get one response partly because that's where independent and our salaries aren't quite as high the second thing is you really can't hire a care coordinator now even UVMs have a hard time finding care coordinators and some of the nurses are some of their social workers but for this whole system if we think it will work it's going to need more of those one thing I would like to suggest I got my two two minutes here so for loan repayment for physicians in this state if you go to work for a 501c3 corporation for a 30 year loan you pay the first 10 years and the subsequent 20 years payments are forgiven and if you go to work for an independent practice that's not the case so I don't know if you all can fix that or not but it's a big determinant of where people end up practicing the AHEC program is good you get one year and then you got to reapply and figure out how to do that and we've used that for both nurse practitioners PAs and physicians but again it's a yearly thing and then you have to see what you can do whereas the program the 501c3 is qualified for you get 20 years of payments forgiven if you pay your first 10 years and that would be nice it would be nice to see that applied generally across the population or across the various practices looking at the board does anyone else on the panel did you I would point to Dr. Parris about the hard work that we've done on recruiting for primary care and we need more primary care providers and it's just so difficult and he could speak more eloquently about that and just also underline what Dr. Haddock said about giving his first born for a psychiatrist and that it's true we're very fortunate we have an excellent psychiatrist we can work with but that was a gift and it's a rarity Dr. Parris do you want to have a few words or I don't know the mic it is an ongoing challenge Chairman Bell had mentioned what the board hears and what our traveler costs have been our experience has been $1.2 million in just three years of traveler costs and it's not just traveling nurses it's travelers in the tech positions lab tanks, radiology tanks respiratory therapists P-T-O-T-U-N-A there's travelers everywhere so it is our job to think creatively about what we do we're investing in workforce housing we just bought a condo last week and the hospital did we're going to put folks that are due to the area then waiting to buy a house in that condo and subsidize their rent a lot of us who run older smaller hospitals have campuses with buildings we don't use anymore so we renovated one and made two apartments out of it so I think we have to think that way I think the next step for the smaller hospitals to think like UVM has speaking about complex patients what have been described as hospital dependent patients I think of what UVM did with housing for some of their complex diabetics and actually addressing social determinants of health actually providing some housing for some of the complex or hospital dependent patients that we have are things we're going to look at I didn't introduce myself Joe Paris succeeded Richard at Montesquati Hospital with one person in between as CEO also chief medical officer first out of his career in primary care so see things from all sides here and also believe her in what she was trying to do great I'll turn it back to you chair Mullen again I just want to thank the panel I know that you'd probably much rather be working with the patients in the field and getting results and come here but it's important that people hear what's actually happening out in the field and I especially want to thank Dr. Holmes for putting this together I don't think it's an advertisement I think it's an educational event that people need to get the feedback from the field to make sure that the hypothesis is being proven correct and I think that there's a lot lot more work that needs to be done to be successful but we're making progress and I think at times we don't focus on progress as much as we do on all the things that are left to be done so I'm very grateful to hear from people out in the field that are really seeing some good positive results and otherwise we'll be just wasting our time for the last couple of years so this is very good and I just want to especially thank the legislators who came today being a former legislator I know this week before town meeting is a crazy time as everybody's trying to get bills voted out and such but it's an interesting year when I look out there and I see so many new faces on the health committee you are the future you are the ones that have to get the message to your colleagues at the state house and I want to take my opportunity to do the sales pitch that really we need to address workforce or we're really going to be in a very bad situation so with that I'm going to recess this meeting until 1 o'clock and again thank you everyone very much so we're going to call the meeting back to order the first item of business is the minutes of Wednesday February 20th is our motion it's been moved and seconded to approve the minutes of Wednesday February 20th without any deletions, additions or corrections any discussion seeing none all those in favor signify by saying aye any opposed thank you so the first item this afternoon is the discussion of the qualified health plan plan design and with that I'll turn it over to our friends from Diva oh yes yeah so Addie Dana we have a court reporter here for the next presentation which is in part on the ACO's request for budget adjustment so we'll let you know obviously we'll just start yeah not yet a little bit of relief over on that side thank you whenever you're ready so I'm Dana Ghoulain from Diva returning from last week and I'm here with Addie Stremolo also from Diva do I have Julie Pepper and Brittany Phillips from Wakely on the phone entry and exit announcements have been turned off for all new participants there's Sean hi Sean, Sean Sheen from Diva do we have Julie and Brittany from Wakely Consulting yes open up John can you hear us we can thank you just confirm okay so I wanted to start with responses to the questions that we received since last week when we were here so yeah we would turn to the 29 so the first slide okay so the first question was around the placement of the chiropractic and physical therapy co-payments for 2020 and how they've moved from the previous year and was their consideration of going in 2020 the requirement for Mach 7 is that the co-payments be placed at a percentage of 125 of the primary care office visit and 150 percent we have proposed placing them at or near the 150 percent mark so starting with the silver plan or to give a little context of our discussion there was discussion about how and where co-payments understanding that it was a transitional year for both chiropractic that last year was aligned with the primary care visit and in 2019 the physical therapy co-payment was still aligned with the specialist visit so in most instances it's a decrease for physical therapy and in most instances it's an increase for chiropractic for 2020 so there was some discussion about where to land and we thought going somewhere in between where the primary care office visit and specialist visit was kind of splitting the difference was the best course and that looked like about the 150 percent level I do want to point out and up a bit that in the platinum plan between 2019 and 2020 where again this was not required in Act 7 but we elected to make a change it's an actual decrease proposed for 2020 in terms of what it would have been if it had stayed aligned with the specialist office visit so that's what I get for taking my glasses off okay pointer for 2020 we proposed moving the PCP office visit from 10 to 15 specialist visit from 30 to 40 so if we hadn't made any changes or if we had kept the same pattern the physical therapy and chiropractic visits would have been at 40 so we went to 20 with them this year in our proposal so it's you know a decrease just want to point that out so I think the main question that we had Dana on that is if you had gone to the lower end of the range would have thrown it out of the actuarial value range that's required I did ask Winkley to confirm that and in 2020 if we made we went to the 125% they would still be in compliance with the AB the three plans in question which was the silver deductible and the two bronze deductible plans would still be in compliance the chiropractic services in fact are not part of the AB calculator that physical therapy services are but we still stay in compliance there would be a very modest premium impact by going to the 125 level and did Winkley give you an estimate of what that premium impact would be? very small it's actually 0.05% so given all the negativity that we received last year being accused of not following the development statute regarding chiropractic why wouldn't we try to go to that lower end and not subject ourselves to what I'm sure will be some intense accusations again this year I did confer with the three primary stakeholder groups with this question that is across MEP and for my legal aid I didn't get an absolute consensus about this but the strong leading two of the three stakeholder contingencies supported staying with the current proposal for avoiding the premium impact small as it is and landing somewhere in between where the specialist and PCP visit would be and we of course want to move the physical therapy and chiropractic co-payments in unison so and then bottom line is that we can't accommodate this change if that's the wishes of the board can you talk to the goal change because I know we don't have to stay within that but I've got the chiropractic on the goal I think it was maybe on the alternative plan the recommended plan brought the chiropractic and physical therapy co-payments to 150% and again that was optional which in fact is just a lateral move this is 2019 would stay the same for goal and platinum the act 7 doesn't apply so we felt that we did have the discretion to bring these up in the alternative plan in exchange for a slightly lower increase in the medical out-of-pocket maximum and a slightly better bringing them back to you but again this was the recommended plan so it's correct that this is over 150% but our understanding from act 7 was the requirement didn't apply so that we would have that discretion we chose to but we would have to go to that plan if we had the restriction on the 8,000 or 8,200 when will we go to the alternate design plan we wouldn't have to we are proposing the plan design in the middle of town we just always kind of show the runner up from the stakeholder group in terms of an alternative design we don't have to switch to that so we bottom line we can't accommodate that just depending on the wishes of the board the next question I wanted to go to was around timing and contingency around that maximum out-of-pocket when that would go kick in and so forth just wanted to switch this here when I gave a brief, high level overview of the remaining timeline items I want to point out here it's estimated that would be made available to us when we would know in April which is awkward timing it's often that way but Julie and Brittany correct me isn't the usual timing about 90 days from when the draft notice comes out which this year was in January I think getting the specifics wrong may have 60 to 90 to 80 a public comment period and so I think that was kind of an equal time frame and also Brittany or Julie if you wanted to review that slide 21 where you outline the contingency plan around the affected plans in silver I'm on slide 21 if you wanted to take a look at that yeah this is Brittany I can go through that so if in the final regulation the annual out-of-pocket maximum moves from 8,200 to 8,000 the recommended plan designs that would be impacted as shown here are the bronze deductible plan with the pharmacy limit and the silver and bronze high deductible health plan so should the final regulation reduce the out-of-pocket maximum 2,000 on both HDHT plans we recommend moving the we would move the embedded out-of-pocket maximum from 8,200 to 8,000 with those two design designs and beyond that no other changes to the plan design would be required we would meet the AB requirements with that lower limit for the bronze deductible plan with the pharmacy limit the recommended plan design would not meet the continue to meet AB requirements with an 8,000 out-of-pocket maximum rather than 8,200 so in that case what we're proposing and what we're approving is that should that happen we would move that to the alternative plan design which is shown on slide looks like 35 from last week's slide down so in order to meet the requirements with an 8,000 out-of-pocket maximum we would need to increase the medical and pharmacy deductibles further from the recommended plan design from 6,000 to 6,350 and for the medical out-of-pocket and from 1,000 to 3,500 for the pharmacy deductible so I hope that answers your question our estimate of time is April and these are the changes that we anticipate and how we would implement them with that final request for the ability to just make that substitution if we need to I think I'd ask wait we've addressed this one as well the question around the trend figures that were provided for the 2019 to 2020 we're going to calculator sure this is Brittany again so the federal calculator is based on data from the underlying data from 2015 and each year they trend that data forward to try and reflect the medical and pharmacy plans of 2020 so the trends that were provided there from 2018 to 2019 and from 2019 to 2020 there was a note that those are quite high these numbers are from CMS they're part of the actuarial value calculator which were required to use to determine the meta levels for these plans so there's not really any discussion about the trends that are used in determining this I would kind of say that I think Julie mentioned this in last week's meeting that the actuarial value calculator is really meant to bucket plans and speeds meta levels and kind of make it an easier comparison to road-like plans so all the platforms have a similar AB those things are really meant to do that bucketing and not necessarily the pricing the pricing or those types of things those will be done by the carriers using their data the trends that they use actually determine the variance may be lower than those from here this is really just for the calculator and will be required to do that bucketing into the different meta levels that help answer that question yeah it does, thanks okay I think I've done that so I guess in terms of written questions I just wanted to acknowledge the questions proposed by Member Pelham about alternative services and acknowledge that that's not something that we can deal with for 2020 and in fact the first suggestion would require addressing or changing our benchmark plan the essential health benefits benchmark plan which is not impossible but a longer term effort that we would need to do with multiple inputs so through Mike sent over two requests and one has turned into a question and one into a conundrum so I think from what I heard is that you're addressing the conundrum just a little background on that last late last fall read an article in the Times Argus about this group called the Vermont Center of Health and Behavior at UBM and they had just gotten this NIH funding to do evidence based clinical studies on different solutions to healthcare problems and behavior and so I went over and met with them and this $31 million grant was a renewal of a $31 million grant that they had before and they have all these clinical studies that they do and we started talking and it was very clear to me that they knew a lot about clinical studies but had no idea about kind of and literally no idea about healthcare in Vermont which is something that I'm pretty deep into now and at the other end I didn't have any experience with doing clinical studies and so I asked them the question of the kind of thinking that when I look at these plans that somebody can go and get a preventive consult with their primary care physician but then if they, for example were told that they're pre-diabetic there really wasn't a solution to that problem other than going through the hoops of co-pays and deductibles to get to the foreman and I was mispronounced that so I was just thinking are there ways to put some preventive measures that clearly have a healthy present value and are the right thing to do and they said there certainly are and for example, diet and exercise for pre-diabetes is one and so my thought was and this is the conundrum was that is there a way to use the 2020 process because I realize that we're into the game on 2020 but to look toward 2021 to see if some of these evidence-based benefits and the folks at the Vermont Center emphasize three of pre-diabetic smoking cessation for pregnant women and heart rehab as three that are just evidence-based and helpful so I was hoping that in this process that we could explore those but I have learned from Wiser Minds that the whole process of opening up the benchmark plan is a complicated one and can be a complicated one so I'm at a conundrum on that I just don't like voting for a plan where if somebody is pre-diabetic they can't have as a benefit a diet and exercise a diet and exercise regime that they can go outside the system a little bit to the blueprint and maybe do some of their self-determination efforts so that's an issue that I'm just opening up to the board and I think I'm going to want to discuss further I know that you have a stakeholder's process and I would like to kind of make our benchmark plan more consistent with what we heard this morning from the one care folks in terms of having it the support of preventive measures and so I'm not making a proposal at this point in that regard and I agree with you it's not a 2020 issue in my view it was a 2021 issue for trying to set the stage for that the other request had to do with just affordability and as you know from the work that you folks have done and Sean has done and Agatha has done that the affordability from a premium point of view of these benchmark plans is pretty good up to 400% of poverty there the premiums are in the 4-5% range but as soon as you get above the 400% of poverty but I said this the other day the premium jumps from $82 at 350% of poverty for the low cost of bronze plan to 400% at $150 a month and then it jumps to $850 a month for the, if you're at 450% of poverty and I'm just looking for this process and I think I heard from Revancer at the last meeting just to have the folks at Devin I think Sean is very capable of this to kind of price out what it would be to subsidize folks in increments between 400% of poverty and 450 and 500 so that their premium is no more than 1% of their income I just because when you look at the deductibles for the silver plans and the bronze plans those have been growing at a double digit rate since 2015 if they're 10 and 11% average annual growth rates and it's just getting very expensive for a lot of people that don't have anybody else to help them they don't have an employer they're out there on their own with a budget of people in the individual market hopefully we can find a path to help them but from my perspective I just need to know a number what is this is it a number that's out of reach and just not possible within a budget process or is it something that we can focus on and help people with Thank you so we definitely have both questions we'd like to bring that into a conversation that is approaching the concern around affordability and the unsubsidized sliver of the market that you're addressing in a kind of holistic way so we'll be happy to be in touch about that once we get through this plan design station Thank you That's why the first one turned into a conundrum because a wise reminder here who has been through that process before of revenge marking is picking one benefit as valuable as it might be and putting it in play that there's a whole bunch of other forces that want their benefits put into play too and it gets very complicated I think Tom, though if you wanted to invite the academics to come and do a presentation before the Green Mountain Care Board so we could all understand it better certainly if there's a way to save money by doing things differently would be willing to look at that It was kind of an epiphanal meeting that there were two sets of people kind of playing in the same part and I had little insight into their world and they had little insight into mine they would love to come so I will work for you to make that happen Great Thank you Any other questions? Was that all the questions? Those were the ones that we received I guess I'll start then and correct me anybody that if I get the scenario wrong but I remember at the end of last year after we had gone through the same process a year ago that certain legislators had accused us of not adhering to the law and the design and they went to the drawing board and they tried to create their own solution to make sure it didn't happen again and one of the arguments that we were hearing at the time, for example on chiropractic is that out of pocket could be the vast majority of what the actual charge is for the visit and do you really want somebody going to a much higher cost provider that might be prescribing opiates or something like that just because it would cost them less out of pocket so that was one of the discussions that I remember having and I think the senate version of the original draft had a limit of 50% of the actual office visit and at the end of the day the final language in the bill was 50 range and I just don't feel comfortable going through that whole exchange again and it's not that I would feel uncomfortable if I felt positively that it was the right decision but I just look at it and I know some people question chiropractic effectiveness but when I owned a distribution business I had two gentlemen who worked for me that would have missed a lot of work if they hadn't gotten to see their chiropractor and so I've never had to see a chiropractor in my life but as an employer I saw how it enabled those two men to come to work on a daily basis and be very productive so I would like since it's not going to affect the actual value of the metal levels to at least have the board consider it but I don't know where the other members are so I need to hear from you I'm happy to jump in it seems to me like this is a not uncommon occurrence where the legislative intent to as you said Kevin ensure that the chiropractic copay was accessible givens or the frequency of visits and where those payment amounts are kind of collides with the actual statutory text which set a percentage amount and it was very helpful to me to read a report that was submitted by Diva last year to the legislature that kind of went through the where the expected copays would be which are lower than where it turns out they ended up because of the way the AB calculator works and updates and stuff like that but so that's really my preview to say I think I would be supportive of moving those copays for those three plans to the 125% level so that we are meeting the statutory and really what we're saying is rounding up to the nearest $5 right Dan? Yes. Yeah. So I'd be supportive of that. What other board members? Well I will defer I mean I wasn't here for that whole Act 7 issue and whatever the consensus of the board was it has more experience through this than I did to support that. I'm also supportive of a lower copay for those. I would just say just to be clear is that at least when I did the math for the bronze deductible without RX limit it still puts it in the $50 range which was at least in terms of one of our comments folks were hoping to see the copay be below that which is not I think is just not able to happen with the statutory language so I just wanted to say that out loud so that I don't think this fix fixes the problem totally but I think it's what we would be able to do to help meet the legislative intent within what they actually wrote. Okay so before I open it up to public comment I just want to state what I think might be the motion so that the public could comment on that and I think what the motion might be I know we make the motions myself so I'm just guessing here but I think that what the motion would be and Robin will correct me if I'm incorrect is that we would approve the designs as brought forth to us by Diva with the one change being moving the copays for chiropractic and PT to the lower 125% range rounding off to the $5 interval. Have I got that right Robin? Yes although I think the other piece we should include in the motion which is unrelated to that issue would be the forerunners discussed on slide 21 which would be after the alternative from the deductible plan and approval for out of pocket changes as proposed regardless of whether it fits within the prior guidance. Correct. Okay does any board member have anything to say before we open it up to the public? If not at this time I'll open the discussion to the public for any comments. Please direct them to me. Yes Walton. I just want to thank Tom for his comment about the over 400%. He made a really good point about people being out on their own. I hear that all the time in my being out in the real world or beyond the bubble here. He hit the cliff. Yes. That's something I think we should or should be pursued more. Other comments? Well this is a very quiet crowd. Thank you. Robin would you like to make a motion? Yes I would. I would like that we move to approve the plan designs as brought forth by the Department of Vermont Health Access and described on page 20 of the slide deck with a change of moving the copayments for card and private physical therapy to 125% of the primary care copayment to a $5 increment and to approve a move to the alternative plan design for the bronze deductible plan with the prescription drug limit if the federal government modifies the out of pocket maximum making that a requirement and to approve the out of pocket maximum changes as proposed on slide 20 regardless of whether the previous guidance would require it or not. Okay before we get a second I just want to ask Addie and Dana have we got it right? Yes I would like one clarification was the motion to move the CHIRO and PT copayments for the three plans in question? Yes. Not across the board but for the silver and bronze in the two bronze deductible plans. Thank you. Okay is there a second? I put up a summary of that. Okay is there any further discussion by the board? I would just like to say one thing before we vote which is that I think this process is a hard process because it's very technical it's very bounded by federal law quite frankly the good part of it is that it's very well done through a stakeholder process before it comes to us but quite frankly the bronze plan I call the population health management ratio and it was a requirement that one care must fund its other population health management and payment reform programs and specifically outlined the value based incentive fund the basic one care PMPM the complex care coordination program and the PCP conference of payment form pilot in Vermont at no less than 3.1% of its overall budget 3.1% the overall budget as calculated here was both the benchmarks for our programs the gross targets and other operating revenues essentially that we receive as any contributions from the payers and the participation fees and that is the denominator and the calculation and the numerator are those expenses so the reason I'm here today discuss this one is that while all the programs have been rolled out in the design of the budget presentation meaning that we've executed them in the way that they were presented to you a little over a year ago for a number of reasons the PHM spending ratio ended up being a little bit less than 3.1% yes 3.1% I can explain those here alright so I mentioned that the overall budget so it uses that those benchmarks and just from a functional standpoint this one's an interesting calculation in that both the numerator and the denominator are variables in this the total budget changes with our benchmark any attribution attrition we experience throughout the year so that's a moving target too and the actual PHM spending the blueprint replacement funding was excluded from the budget order so I've done my calculations accordingly and these are current pre-audit financial estimates with the total overall budget 626.8 million and the total eligible PHM expense 15.4 million the next grid down below itemizes the variance by the different initiative that is applicable to give you the context here of some of the numbers and then I'll explain them each and the primary driver behind each of these variances that we're seeing so care coordination came in under the budget level there's a couple themes that we'll be recurring through the talking points here but two primary factors that drove this variance the first was lower than expected attribution we've talked about this here in the past where the blue cross in particular attribution came in significantly lower than we had modeled in the budget the other factor or one other factor that is material is that we had a delayed start to the UVM Medical Center self-funded plan those payments began after Q1 so beginning in April that causes really two delays one is that we just didn't have any payments in the first quarter but there's certainly ramp up for these new programs when you get your population into the high and very high risk categories it takes some time for that level 3 engagement to take place and that also resulted in some spending below the budget level last I did and there's not a bullet point here but we did have some estimates in the budget for that level 3 engagement of care coordination across all programs I think it was a learning that we had but a pretty aggressive engagement rate and we haven't quite hit that rate I think it's a good target for us to keep striving towards but our actual engagement has been a little bit below the estimate that was incorporated into the budget model next we have the comprehensive payment reform pilot this budget was $1.8 million and that was really built to accommodate ten practice sites that we had modeled as being in the network in all three programs and independent only three ended up joining the pilot which actually was an outcome that was totally acceptable and that there were three great sites two of which were really some of the larger one of which was the largest and then another one was at the upper size threshold so it's not like we spent three tenths of the funding but just three of the larger sites and really the budget variance here reflects this lower participation in the program there's a balance to be struck that I had which was we had this budget number in here we had fewer practices absolutely want to invest in the practices but need to do so in a sustainable manner and if we unlocked the full budget amount to those practices my fear was that we over found this work in a way that wasn't going to be sustainable long term and it resulted in us needing to pull back I did not want that outcome so we essentially left unfunded dollars in the table that was part of the modeling I did to determine whether or not we could hit the reserve requirement kind of naturally as I knew there was going to be some savings in this area in fact and in that into the calculations the value based incentive fund you'll know is basically on budget but just mentioning it here as it's one of the program components just to bring it up as we're getting close to our 2018 have our final numbers in the books we accrue and set aside in this restricted account essentially the full amount that were required to hold aside by the contract so it's a percentage of the total benchmarks with a half a percent or one and a half percent of it on the payer program ultimately we get a score quality score at the end of the year and that results in a certain amount being just paid out to the network and then there's a remainder that is either split and payback to the payer or retain for investment for future quality initiatives this number that I have in here is the full amount that we've accrued since we do not have that split so just to make sure everyone knows and understands that piece the last category here are the community program investments in here are the Howard center sash pilot with the embedded mental health and the sash housing programs the regional clinical representatives which we pay out to each community to have a clinical liaison essentially one care month and then rise Vermont the biggest component of the budget variance was driven by rise Vermont and the roll out much of the funding that one care it pays for rise Vermont and invest in rides Vermont is related to local program coordinators that the the entities in each community higher and when they hire those positions one care matches some of their salary to help roll out this initiative statewide so as those communities hire those positions we began to match the funds and thus had much higher costs in the second half of the year yet there were still and there was still a budget variance the other component of the budget that came in under on the cost side was the amplify grants so basically once the program coordinator is in place each community they're coming up with ideas for how to engage in prevention and wellness in their area and then we give them access to these amplify grants to do innovative and fun ideas that rise Vermont can speak to better than I can and basically you got to have the position in place first before these grants start so we also started to see those escalate in the second half of the year alright so then the request ultimately when I look at where we landed 2018 with preliminary numbers we ended up with a phm ratio of about 2.5% so we're a little bit below that threshold in the budget order again the important point at least for me and this is why I'm confident coming here to say this is that we've rolled out the programs in their designed manner and the manner of the budget presentation that we submitted to you a year ago a year and a half almost it was really the variance or the not meeting this budget order was driven by changes to attribution participation and the timing of the program rollout particularly for the self-funded and rise Vermont and then just in terms of the linkage between these two orders in some cases the savings here did help us contribute to the reserves and avoided further increases in the hospital invoices I'll pause there I'm just curious about the management of the budget for rise Vermont is that in the hands of one care do you see the whole picture in terms of what your contribution is to and what the local share is increasingly yes I'd say in 2018 the exact path for rise Vermont and the fork in the road was really to be a completely independent organization doing its own financial management its own budgeting but having some investments into one care was one path the other path was more of an integrated model into one care's population health strategy and fulfilling that quadrant one objective in 2019 it's much more towards that second avenue which is having rise Vermont more integrated into one care and thus having certainly more insight and control over the financial arrangement the second one is what I understood it to be and it sounds like there's been some transitional issues in 2018 into 2019 I would say that there's just the transition from being a singular community model to a statewide model had just ordinary growing pains that you go through to figure out how you make this sleep so I got the impression that the rise Vermont budget came in hot relative to what the expectation was can you give me a sense of how much that was the rise Vermont budget if my memory serves me well for 2018 was I believe 1.1 million and I have this number in front of me but I think the spending in that year was in the ballpark of 700,000 other questions from the board? yeah this one's a little more concerning because I totally understand that things didn't gear up as fast as they could have and things like that and so you came in at a lower percentage but we haven't seen your full 18 budget but you're obviously alluding that you're going to be break even with providing for the reserve and this wouldn't be the place of the savings you've got 4 million of savings well it went somewhere I know part of it I think your top line didn't come in as high as you thought but it's offsetting the reserves and legal and things like that that's where it's concerning and that's why there's a percentage to kind of say we're staying at the 3.1% so that the dollars that you get in are being spent towards this really important program so I guess for me it really it happened you closed your books you're at 2.5% there's not a lot that we can do I think about the past but it would really be a caution for the future that I definitely wouldn't want to put up this contributed to reserves and things like that in the future and that there were savings to these programs that offset other expenses so I mean that I feel like we can't really do a lot about what happened last year and I again totally understand there was slow coming to get some of the programs up and running but it would have been great to have put those to the bottom line or put it to reserve or had it dry powder for this year for 2019 rather than to have spent it I feel like we can't do a lot about it I mean you'd either be out of compliance on this but that's what it was and I think here to Kevin's point of knowing more timely and things like that because we didn't have an option to say you're going to be favorable $4 million in this area where should that go or how do you do it so I just think for sure for next year we're really going to want to make sure or I'm going to want to make sure you're not utilizing this as a fund to offset overages yep totally agree and I appreciate this and I did at the time that the budget order came through it still do appreciate what this is intending to do we're coming to you with a budget model that says we're going to invest in these areas in this fashion and I think the budget order is intended to hold us to that and make sure that we do invest in those areas and as promised in the budget presentation we have some ideas for how we can satisfy that in a little bit of a different way because I think this ended up being a technical thing rather than whether or not we actually fulfilled our obligations under these program models and welcome a conversation on that front but I totally agree with what you're saying Tom one thing is that we try to give the earliest that we could probably vote on this would be March 13th it's a pretty packed day which would take us to March 20th we could do it on the 13th for the timing issues for you really the only timing issue is particular to the reserve component at some point if I need to get to 2.2 I need to invoice the hospital so that they know that this is coming I think based on that timing it's okay I can kind of inform them at the next finance committee that it's it will be resolved and the date actually might align just fine with that so when you say the date the 13th would be preferable I'd have to look at the calendar to see if that's before our next finance committee no no I think that would be fine are there other questions before I open it up to the public I'll just say that we will be taking public comment and get on the site so would anybody like to offer a comment or question today? Dale I read it through last night and sorry it hit me as a puzzle there was a lot of time choice it hit me as a puzzle when I've read this last night because I'm watching money flow around in the sense of we want to change what our reserves are I'm not sure if I'm using the right term we want to go to the 1.2 or 1.4 million from the 2.2 or 2.4 million and I don't have any information as to is that an adequate reserve I don't have anything that really gives me much guidance in terms of were you here when Maureen gave her explanation about the re-insurance agreement whatever you want to call it and how that go away from the need for the higher amount I may have missed it because I came in late sure yeah and I'll actually give you two things one when they originally did their budget they had in 1.5 million reserve for allowance for re-insurance and we increased the total reserve to 2.2 million and still increased them to go out and get re-insurance they did get re-insurance for 700,000 and now they're putting in a reserve for 1.4 million so that is 2.1 million of the 2.2 that was requested and the other piece just as a reminder is the hospitals really hold the reserve the main part of the risk and would have to pay that out should they risk corridors barring in 2019 when there are a couple hospitals that these guys are going to cover if the worst case happens and we hit into those risk corridors and that would be what they would have in for what they put in for 18 and 19 would fully cover the hospitals that they say they're going to protect so just remember the hospitals are carrying the bulk of the 30 million dollar risk that happens where the re-insurance and the hospitals are supposed to pay that not, you know, the ACO that makes more sense to me I'll give you a comment go ahead does that fit into this conversation anywhere where their administration we didn't get the first part of what you said Dale the administration administration costs they have I know like the SASH discussion what to do with administration funds I keep trying to figure out they like this morning they were saying SASH services are covered in the ACO but there was a budget cut elsewhere right and I got budget cuts over there that are going to affect the services they're delivering but when they do a presentation they're saying well we've got to cover we're going to cover the services there's a disconnect there in my mind so it might be in my mind too because I took it that your services were going to be covered but the cuts elsewhere might cut other services am I getting that wrong Tom? my understanding is that funding for SASH comes from two primary sources one is now one care and that's from the blueprint replacement funding my understanding is that they also receive funding through the state of Vermont that covered the bulk of their administrative operational costs and that is the component that is in discussion to be cut and they're looking for a way to backfill that potential loss that comes down well and if it's helpful in the negotiation what Medicare was willing to fund was the cost of the services which was as Tom said the 7.5 million they don't fund admin Medicare will not so that was a cost that the state had to pick up because of federal funding restrictions but either way the discussion at the legislature now doesn't impact the 2018 which is what really we're here talking about today the past budget yes but thank you I just wanted to point that out because I know that's going to be an issue going forward so I wanted to point that out because if you want to talk with them over there and let them know what they are thinking may not be right I think they might listen to you more than us I try now continue to thank you that's my biggest fear is that everybody thinks that there's this vast pool that healthcare is going to pay for everything and that they can back away that's just not the case that's true other yes ham I wonder if the board has any thoughts at all in this area one of your one of the hospitals involved here in the one here goes into chapel it could happen I think it's a smaller piece but have you done any you know we haven't specifically I think this is one where we just need to wait to see what information comes out and then react based on that information and we can speculate about different scenarios right now but I'm not sure that does much in terms of productively moving this forward based on current modeling wouldn't you owe them for 2018 they're all hospitals are modeled as receiving some shared savings and my current modeling suggests they're all net winners meaning that after their participation fees as cost to them plus the population health receipts that they get and their performance in these two-sided risk programs that they're all what I call net winners so this isn't a bigger question we don't have an answer for this how will the attributed lives be treated if there is a bankruptcy filing some would argue that the attributed lives wouldn't be effective because the hospital will continue on under the protection of the court there could be others that might argue differently but we don't see this as a significant threat to your organization do you I do not have other questions or comments from the public again quite a day so Tom we will schedule this for a vote on the afternoon of March 13 we are opening it up for a public comment today for anybody that wishes to comment on the issue and we'll see you in two weeks great thanks so much thank you so with that is there any old business to come before the board seeing none is there any new business to come before the board seeing none is there a motion to adjourn so we move from second to adjourn all those in favor signify by saying aye any oppose say nay thank you everyone and have a great rest of your day