 That's all I'm doing right here. Welcome, everyone. We're going to get the meeting started. If we could start with the executive director's report. I understand it's very short. Yes, I have nothing to report today, Mr. Chair. Thank you. Is there a motion on the minutes of April 22nd? I'll live up to a little bit of minutes. I'll second. You can move and second it to approve the last week's seven minutes without any additions or corrections. Any discussion? If not, all those in favor, stand by by saying aye. Aye. OK. Ina and Melissa and team, could you come forward? Seven songs that you are going to do with one. I won't begin with the songs. We'll face them for last. We do have an ensemble presentation for you this afternoon about the regulation of the accountable care organization and the implementation of the Vermont All-Hair accountable care organization model. We're going to start by giving you an update about the accountable care organization regulation that we do here at Green Mountain Care Board, both in terms of ACO budget review, as well as ACO certification. We'll start. You heard from One Care a few weeks ago about the status of their budget, and they gave you an update. We're going to give you an update from the staff perspective in terms of what we had our eyes on and what we're anticipating going forward. The second part of the presentation we'll talk with you about the model agreement and what we're doing to bring about changes for 2019 and how the model is being implemented at this time. I'm going to start by passing the mic, and I took it out so I could pass it easily between the ensemble members. To Melissa Miles, she's going to talk about budget order monitoring. Next, it's going to be at your piece, so that we can monitor that. So per the budget that was approved for One Care of Vermont at the end of 2017, we had over 20 items that we are now monitoring for 2018. And I wanted to give you an update on those and also what's to come. So in the first quarter, we received a scale target analysis of the different ACO model contracts that they have, and also a contract alignment report. And we've received the Medicare and commercial contracts, and we have had an opportunity to evaluate those reports and do feel that those contracts all meet the scale target ACO that is in the all-care model agreement, and as well, their contracts align in the areas of quality and risk. We have those on file for review if you would like. So we are waiting on this off-insured contract, and One Care has told us that it's coming shortly. But once we receive that, we will also evaluate that to ensure that it meets the scale target ACO definition for the all-care model agreement. Secondly, we've received all of the hospital risk contract addendums, and I thought I would read off the hospitals just for review. So we have UVMMC, CVMC, NMC, Porter, Browneboro Memorial Hospital, Springfield Medical Care Systems. We have three that are participating in the Medicaid only program, and that is Southwestern Vermont Medical Center, North Country Hospital, and Mount Miss Ketney. And on file, we also received a letter from Dartmouth. So we also required Dartmouth and UVMMC to provide letters of credit to cover some of the risk, a portion of the risk, and we have those on file. And then One Care was tasked with taking their grievance and appeals policy and taking it from a Medicaid policy and expanding it to all-care, working with the health care advocate on that, and they did complete that task for our certification review actually, so that was completed back in March. And then we also have an attribution by county for each payer. So I was having a question. If you'd like us to ask questions when you're on the paper slide or hold them for the end. I think ask questions as we go would be fine with me. I think we're the only show today, so. So my question is on the letters of credit, were they equal dollar amounts? Yes. OK. Yes, they were. And we tasked them with that amount. And I think it was 1.1 million plus for each Dartmouth and UVMMC. It was a letter of credit issued through a national institution or how did they do that? They were written by each hospital. They were the same though. So I'm assuming that a lawyer drafted them for each hospital to them send to us. Thanks. OK. So I was asked to review the one-year Vermont Project Highlights for 2019. And you've seen the slide before. But for reference, I wanted to talk about their attribution. When they submitted their attribution last fall, it was about 122,000 lives. And when those contracts and attribution were finalized, we did have some shifting in the total numbers. So they saw a 19% increase in what they thought would be attributed for the Medicare population and then a 40% decrease in the commercial. And Medicaid stayed fairly close. It was a negative 4% change. So that also shifted the total dollars amount. And so it's 638 million, 548, 140, and with their PMPMs. I also wanted to provide an update on the quarterly operating results. We will see the first financial results for one care, budget to actual, as well as for the hospitals and their fixed perspective payments by payer. We'll receive that the week of May 21st. And accordingly thereafter, they needed to close out their first three months and then have it go through their board prior to it being submitted to us for a final version. Along with that reporting, we'll also be receiving attribution on a quarterly basis by payer and health service area. So this is a slide about what's coming next. And so by honor before June 30th, we'll be receiving a medication-assisted treatment provider update to assess their network capacity, as well payment differential report. And then they are supposed to have 1.1 million on the books for reserves. And finally, something that's not in the budget order, but that we're working with one neuron is a data presentation that we're hoping to see by quarter on the health service area results. So we know that data is a powerful tool and we're trying to bring some in with more real time. It's difficult with claims lagging so far behind. With the 1.1 million reserves that they time out, they still have that potential for the main insurance policy. And last, when we talked about this, they said that was a possibility, so it's kind of a need of work. Right, exactly. And at this time, they had said that they were leaning more toward the reserves. How many mats were initially signed up? How many what? Medication-assisted treatment. So when they suspended their budget report to us, they did not know. So they've been having to do that research. And it's not that they didn't know that that information is not disclosed to them. It's more of a relationship between them and the payers. And so they're working on finding out what information it's sending it to us. Okay, so we are wanting to review our budget guidance timeline for the 2019 season. And we're currently working on a draft for the 2019 ACO budget guidance. We have an internal team working on that. Then we have a presentation on the books for June 13th to present to you a draft budget guidance. In May, we're also going to be meeting with the health care advocate and other parties to ensure that we're collecting all the information that we need and also opening to Act 113. So we are hoping by mid-July, we'll have a vote on that. And then that guidance kind of go to the ACO. And we expect that the ACO will not be able to submit their budget to us until October. And that is due to provider lists. The deadlines for provider lists are at the end of September. And so those provider lists will go to Medicare, Medicaid and commercial. And that is what drives their final attribution and dollar amount estimates. And therefore thereafter, we will provide an analysis to you and they will present to us. We'll have public comments. And then in December, we'll be able to vote to establish the budget. When I have firm dates, I will present them again. But we're still fine on my Sundays. So related to this, but do you remember what the date was on the submission of their report on their high rate care pilot problem? Some of the updates on that. Where does that been? Yeah, that's the payment differential report. So that's coming in June 30th. June 30th, okay. Thank you. And then I think that there's also a quality report but that's at the end of the year. Okay, great, thank you. Yep, thank you. Any more questions? I think that we are hoping to be able to include in the budget guidance is guidance to One Care for Mon on how to report investment in primary care. And in order to do that, we are working as staff and with stakeholders to develop a specification for One Care to report its investment in primary care, both in terms of claims and non-claims based spend. And Michelle has said, believe on this work and she's going to talk to you more about it. So this slide just kind of outlines and Nina said right now our primary focus is on developing the measure to be included in the ACO budget guidance. So an ACO specific primary care spend will also be working on a total sort of overall look statewide that will also include some non-claims spending. And then we're also part of sort of internal working group across a few states in New England and looking at how perhaps we might be able to use data that's similar and kind of compare across states. So just to give you some background on the three different definitions that we're sort of working with right now. So the staff right now are working to propose sort of a calculation for the ACO spend and it will likely be presented in five different ways. The first being a total overall ACO attributed lives as a percent of their budget and then the others as you see as a percent of claim spend for the specific payer type. Sarah has been instrumental in her knowledge of V-Cures and making sure that we know what can be included in the numerator and denominator for these measures. And I will say that through working with the primary care advisory group we've narrowed it down to what we believe might be our final codes that, so CPT codes as well as provider taxonomies that we'll use to develop that numerator and denominator. So next steps, the staff again, we're working to develop the claims based spend to go into the ACO budget guidance as well as the non-claims based spend. That one has the potential to be much more complicated as you can imagine. And we're also working and we'll continue to work with the primary care advisory group to receive their input as we move forward to sort of get the provider perspective on what they feel should be in and out, especially if we move on to that state line spend, which will likely be a little bit more broad. Michelle, before you move on, so the non-claims spend would include the blueprint for member per month medical home payments. Are there other examples of what might be in the non-claims spend? Yeah, there are other examples of what would, the ACO indicated a little over a million dollars for instance as being designated for the creation of the primary care capitation program. So that would be an example of investment included in the non-claims spend. And there are a couple of other items such as that that I'm recalling from their budget submission that we think, but we still have this work to do to arrive at the exact specification. Thank you. I was starting to dig around this, that's curiosity. This morning I'm thinking about non-claims versus claim spend and looking into a little bit of organ and what I love that I've been doing because they've been trying to define what this is. And it struck me that there's huge variation in what's considered claims, non-claims, what's in, what's out. It seems like this could be a really challenging task and I was actually struck by I think in one of the, I think it was the Medicaid primary care spend organ, 65% of it was actually non-claims based. So it just strikes me that this is gonna be a difficult part of the process. And I'm wondering what kind of lessons you're taking from those other statements gone before us or how you're gonna come to that final level. I understand you're gonna peek at all that, but. We did have quite a bit more work to do to arrive at a finance proposal. And I think that it's a proposal that we're looking for feedback on or we will be looking for feedback on. But we do have a relationship with the Milbank group and we have called upon them for their insights into this work because they've spent some time measuring primary care spend. And one of the things that Rachel Block shared with us in the PCAG as well when she came and met with us was that kind of despite the differences in how the spend is being, you know, the specification for measuring the spend, that they weren't seeing wild differences in the overall total spend. So even though there's a lot of choices to make between in and out, those different approaches haven't necessarily netted out big gaps. So that's one thing we've learned. That's one piece of learning that we have. And I don't know if anyone else would like to speak to some of the other choices that there are to make. It's certainly why we're looking at doing this differently on the ACO basis versus the state basis because the question for the statewide primary care spend is a much broader question. What's happening at the Department of Health that might be counted and that broader landscape? Whereas the ACO gives us a, in some sense, is an easier test measure because it's a more narrowly defined area where they might be moving dollars and investing them in primary care. In some ways, if you knew what the rate of return on different kinds of primary standards, primary spend, investments would be able to, I mean, you want to make sure that the dollars are being spent in a way that's going to return on investment, right? And so how do we identify, I mean, capturing those dollars in a way that they measure it? So it's an interesting problem. I think the other pieces in establishing the baseline, we don't have a baseline for primary care spend necessarily, we have some estimates, but we don't have, you know, agreed upon settlement on that baseline. So I think from the baseline then looking at which areas of that spend to potentially invest more in is something that we're thinking about. It's definitely why we want to establish that ACO primary care measure in this next budget cycle. In terms of the statewide primary care spend, I think one of the things to think about when you're working on the specification is how we might use that. So for example, if we're using it like Rhode Island, as an example of it in their rate review process, you wouldn't necessarily want to include the Department of Health stuff because it would change sort of how you're looking at it. So I think, for my perspective, we want to make sure that that definition is tied back to our regulatory functions and not just theoretical. All right, rule five, as you know, governs the oversight of ACOs, both of the budget review process as well as the certification process, and there are some updates with respect to rule five that might far be exploited to provide. So having gone through the budget cycle last year, having gone through certification and thinking about how we are going to make sure that an ACO continues to meet the certification requirements. There are some changes to the rule that need to be made. I would say not huge changes, but some tweaks, for example, around the budget review timeline. We have a better sense now of the kinds of documents that we think you would need to review an ACO budget. So we're going to develop some recommendations internally for changes to the rule. Our plan at this point is to seek input from the health care advocate, one care, Blue Cross, MVP, and Diva, present some recommendations to you at one or more meetings, and then once you approve those amendments, start the statutory rulemaking process, which, as you will remember, is long five and a half months at minimum, and it includes hearings before ICAR, Interagency Committee on Administrative Rules, LCAR, Legislative Committee on Administrative Rules, public orders and comments. So there's a robust public process that's part of that. Any questions for Mike? All right, one other thing to mention. During the rulemaking process last year, in front of LCAR, we made a commitment to provide some guidance on a trust referral to the Attorney General's office, which is a statutory duty we have. That was done, it was posted yesterday, basically summarizes some federal guidance that the FTC and DOJ put out with respect to ACOs participating in the Medicare Shared Savings Program, so that went up yesterday. Well, the bills that are in progress that may have impacts on certification, so we should. Should have pointed out at the start of the presentation that in the agenda slide, there are stars that indicate the items that we're talking about today that will, or we anticipate would require a board action by vote, and so the rule five potential changes, rule five is one of those items, as is the budget guidance that would be issued for ACOs and as is the 2019 Medicare ACO Initiative Program Design, which we'll come to later. We're gonna shift now and talk about the implementation of the all-care, accountable care organization model and our responsibilities for our federal agreement. We're gonna talk about now what's going to, what the information will look like and the timing for information to go from a state of mind bring that care board to the federal government in terms of reporting on our key goals and outcomes for the model. And Sarah's gonna share this information with you and walk you through the timing. And then Sarah Lindbergh is gonna provide some context for you about why the timing is what it is. So these timelines might raise some questions for you. Sarah will hopefully answer those questions. Sarah Lindbergh. So I'm actually gonna skip us forward on a couple of slides to slide 14. So the agreement outlines three kind of referring reports to the OCMMI under the all-care model, as well as for one-time reports that we or AHS in partnership with the board are responsible for producing. So today we're gonna talk about those recurring reports and kind of the annual timelines and the quarterly timelines for developing those. But I did wanna highlight that there are also some other reporting requirements that we'll be thinking about in the coming years. So back on slide 11. We are required to report quarterly and annually on total cost of care, both Medicare only and all-care total cost of care to CMMI. This highlights, since Medicare will actually be providing the Medicare total cost of care calculation, this really focuses on all-care. And it shows that as claims that are incurred in quarter one, for example, we won't be able to report on those until quarter four because of the timing of the data flow. And Sarah will explain a little bit more than that, but this just kind of shows we'll be reporting quarterly on data that's quite a few quarters old and those reports will build on each other until we have a picture of the full performance year. That includes quarters one through four and that'll be in quarter three of the following performance year. So that doesn't confuse you. We ended up having to, we initially started making these timelines to explain that to ourselves and our federal partners to kind of show how it all built upon each other and what the dependencies work with the data. So it's a one-year lag? It's a nine-month lag. It's a three-quarter lag. Sarah, is that correct? Great. So, and actually I should have mentioned, our team here, both our policy side folks and our data side folks are working very closely with a contractor, mathematical policy research and their contractor on point health data to specify, test, validate and produce these reports. So right now we've been working with Mathematica since about January and prior to that work with Baylor Health purchasing to start to think about. So total cost of care conceptually seems like a pretty easy thing. You know, you add it all up and you count it and then you divide by number of people but it's actually getting to a specification for that has been a somewhat arduous process. As I think Pat Jones could attest in the audience. So our team is working really closely with contractors to figure out the best way to do that and not just with contractors but validating with payers and with the ACO as well. So we'll start to get test reports on total cost of care over the summer and into the early fall and then we'll be developing our quarter one report around the end of the calendar year. So the next recurring report is the ACO scale target and alignment report and that is both including information on how much ACO scale we have achieved for the percentage of eligible Vermonters who are participating in the ACO as well as conform policy minded description of how well the various ACO scale target ACO initiatives in the state align with each other. So in those reports are due kind of mid year in the following performance year because of the ways that the various programs are attributing members and the challenges of actually kind of developing methodology and counting the percentage of Vermonters who are in scale target initiatives. We have CMMI has granted us the full performance year to do that assessment and then the report on it six months later. And then lastly, we report annually on health outcomes and quality of care. So that's both the outcome measures that are outlined in the agreement as well as the kind of basic quality measures that we've been developing. And those measures most of which are planes based are calculated based on a full performance year to work of planes. So those like the total cost of care reports have a nine month plan. Do you have a template for what that quality report will look like? We do have templates for what each and every one of these reports will look like. So that's a thing, that's a project that we've been working on for the past, I would say a year or so. And they've been somewhat iterative and I would expect we'll change somewhat between what we have now and when we actually start reporting them I think as we fill in the data we'll identify places that where we can do things in ways that make more sense but Jess and Robin actually sat through kind of a walkthrough of those early drafts last summer and we've worked through them with our contractor as well as with CMMI. Could you provide like a sample of what each of the four numbers, just the sample numbers written in basically? Yeah, absolutely. I think that is all on this piece of reporting. So I'm gonna pass it on to Sarah Lindberg now. Any questions for Sarah Kenter before I have one? You're saving all the arguments for Sarah Bell. Thank you. This is the last I'll ever accept to say. Luckily, Nina's last. So yeah, why are these data so gnarly? This is just to give you a taste of how the data flow works. And to be clear, this is for major commercial payers and for Medicaid, the Medicare data comes into be cares on a bit of a different schedule, which is why we'll be relying on reporting from the federal government for that data stream. But if you see here, so when you incur a claim, that's the day you actually want to see a provider and had something done to you for which the insurance company is billing or being billed for. And so that's the patient incurred timeline. So for Q4, the fourth quarter of 2017, people are racked up, I should say, claims. And throughout that time period, the payer is either paying or adjusting those claims. And then we allow what's called a run out period. The gold standard for commercial claims is six months. It tends to take a while to get it right. It's a very iterative process, but because we're trying to get as good a data to view as fast as possible, we're just using a three month run out period. So that's why the second blue line extends in the full quarter of 2018. After that quarter closes, the payers then have a month to submit data for the previous month. So most of our large payers will submit monthly. So the data through the end of calendar month, March, is due by the end of calendar month of April. Then our vendor on point cleans and consolidates and tests that data before it's delivered to us at the Great Mountain Care Board. And so for the fourth quarter of 2017, we'd expect to see that in late June or early July. It's not trivial to take all these different types of claims and put them into one place. And it saves us a boatload of work in terms of mapping people across payers and providers so that we can make sure that Blue Cross's Dr. Smith is the same as NVT's Dr. Smith. Particularly challenging on the member side. And the reason it's important, I just wanted to demonstrate with some, oh no, you shouldn't let me touch these things. Thank you. So this is an example, and this is all three types of payers. So it's Medicaid, Medicare, and commercial that was incurred in calendar year 2016. And you can see if you just look at claims that were paid through the end of calendar year 16, that green line goes, that's the run out period. So even though people got service, there wasn't time for the claims to be paid. Whereas if you look at that same incurred time period but paid through the end of calendar year 2017, you can see that it's much more complete. So that's why whenever you hear someone talking about a completion factor, you're trying to estimate that incurred but outstanding for IVNR amount. So as you can see, pardon me, the June onward is why we usually ask for six months. But three months is what's gonna have to be good enough for what our purpose is. So can you go back to the slide before? Sure. And what happens after we kind of settled all that out and then there really were a bit more claims that came out in that up to the six months? Will it just fall into the future period? Will it be directly just back when it gets in your end? How does that happen? Yeah, that's a great question. And there's lots of different ways you can adjust claims. The way it works in our database is they try to consolidate it into one claim. So what I have in vCures is the first paid date and the last paid date and the net amount. So the claim itself is actually adjusted which makes some analyses really straightforward but figuring out what those deltas are is a little bit trickier. So if you wanted to know what a specific claim was, you'd have to go to a previous database in order to figure out that difference. Does that make sense? That's much as it ever does. But yeah, and the payors tend to come in at different rates. Medicare and Medicaid tend to pay really quickly. Commercial tends to be a little slower. But Medicare and Medicaid also tend to have a lot more adjustments. And the most dramatic adjustments can have really long tails. So you could have a settlement happen three years later and have to go back and make an adjustment. So some people would never call it final final but I think they no longer will and adjust a claim in vCures after five years. Yeah? Great question. So in terms of the on point cleans and consolidates and tests data, is there some data that just can't be cleaned and therefore is excluded? So they process any claim that comes in. So that means that we have claims in vCures that shouldn't be there, such as some people submit like accident policies. A lot of payors will submit claims for people that aren't even Vermont residents. So, you know, they try to do their best to let us know when that's the case. There's a little flag to indicate whether or not it's Vermont resident. That can cut both ways though. So for instance, there's Medicaid recipients that are marked as out of state even though they're Vermont residents, why they have a non Vermont mailing address could be due to a myriad of circumstances. So you can't take it as gospel when you have those things. But yeah, and claims data are messy. It's administrative data. It's not financial data, which is, you know, cleaned and adjudicated through a business office. So it's certainly not perfect, but it's kind of the most detailed, timely source that we have for a lot of this stuff. So is there a way to just get some measure of the amount of claims submitted by payers that comes into the cleaning process versus what comes out of the cleaning process? Is it a 2% differential or a 10% differential or some sort of a magnitude that we should expect that data would be cleaned out of the system? So I would say that as far as I know, they wouldn't drop any claim. So it's all in there. So however, the way the aggregation works can be tricky. So we are actually actively undergoing some validation with some of the payers. And it turned out that, so the way the system that intakes the data works is it can only account for one way to adjust claims. So as I said before, there's lots of different ways you could do it in your system. You could have like the first claim and then say a negative claim for that same amount and then adjust and then have a third claim with the true amount. Some people just have a snapshot of the most recent version. So there's a few different ways you can kind of keep track of these changes. And it turned out that one insurer was using more than one method due to some manual worker rounds. So essentially, unless they have a different submitter ID for each of those circumstances, which is essentially impossible in their claims management system, there's no way we're gonna ever get perfect. But we are doing our best to get the best data in as possible and control for some of these messy circumstances that we come up with along the way. Oh, good! First time for everything. Not. I got most of it. Oh yeah, yeah. And, you know, if there's anything I can do to help illustrate better, I'm happy to provide that. That's all you got? All right. Okay. We're going to wrap up our discussion of all parent model implementation or at least our information that we're providing with you. We can continue discussing for as long as you'd like. But we're gonna wrap up providing information with an update on what we're looking at for the potential 2019 Vermont Medicare ACO initiative. And you are aware that all parent model agreement provides Vermont the opportunity to customize the next generation program. And in 2019 requires that Vermont create its own Medicare ACO program. So while this year we've modified the next generation program, for 2019 we will have a Vermont specific program. That program still can look largely similar to what next generation looks like today and should look largely similar to what that program looks like today because an entirely different system would require a huge amount of time in order to put in place. So we wanna continue to build on structures that CMMI has already architected and that we can use right now. However, we're thinking that some potential customizations for this program might come in the following large categories. Quality of performance measures could be modified. Public facing materials that accompany the program may be modified. And there could be modifications to the ACO government structure specifically so that the Medicare portion and requirements for ACO governance are aligned with what is required in the rule five. And a larger and potentially more critical undertaking for the success of the all parent model is something that would be designed and be implemented potentially in 2020 which would be changes to the attribution methodology. Achieving the scale targets in the all parent model are essential for the success of the model. That's why the targets are there. They are aggressive but without scale, this model likely will not succeed or will not realize its full promise. And changing attribution methodology could be a way to provide for additional scale. So that's something that we are discussing now that we want to discuss more but that would not take effect until 2020 because of the time to engineer subject change. If there's been any discretion around like the three A rule and some of the operations around some of those waivers that are in next gen and where that stands. Yeah, we can. We have been having conversations with one care Vermont about how they are seeking to implement those waivers and there are some barriers to implementation but we think that those barriers are something that can be overcome with further work and research as to how to work within what's a new program. I think there's still parts of the program that are open for interpretation and given that it's a new program for any ACO participating, exactly how to roll out the program is still something that's being worked on but Melissa's been working on this with Sarah Berry at one parent. They're gonna let her go in. So there are three Medicare next generation waivers that were granted through the contract. One of them was for telehealth, one of them was for to wait the three day SNF, number three day hospitalization. Three day stay. Three day stay and be able to be transferred straight from a hospital to a SNF if the provider so chooses and then finally there's one for post discharge. It's called the post discharge waiver, post discharge benefit enhancement which provides more benefits to a patient in the home. It would extend the number of days that a patient would be able to receive home health services and we have been working with one care. They have found some operational challenges with the post discharge benefit enhancement specifically due to billing and it gets technical but there is something called incident to billing and so it requires close communication with a physician which they have but then it requires the physician to bill instead of home health and so home health is not always getting paid for the care that they're providing to no fault of anyone just operational difficulties when providing care for a disparate population throughout the entire state. And so we've been speaking with CMMI that's been talking with their legal counsel and it sounds like the waiver does allow for flexibility for payment and so one care has agreed to test that out with UVMMC and Chittenden County Home Health and we just spoke last week so that's a pilot that they're undertaking to see if it will work. How do we protect the non-attributive life from being a victim of what becomes a standard practice as far as not having to adhere to the three day rule? So the practitioners release that person to rehab with the skilled nursing facility and then they'll be no longer being reimbursed. So we make sure that doesn't happen. One would presume that UVMMC has those patients denoted in their database or that they would check with one care to see if that patient is an attributed life from Medicare to see if they are allowed to have that benefit enhancement. So only labs that are attributed to the ACO have that protection. If someone would get to the scale, I would think the bigger risk is that patients won't get those additional benefits in the short term because the provider is going to be worried about what you're speaking to, can't it? So it's over at some sort of scale, people will stick with what they know and what the majority will be concerned. Right, and from what I understand, also one here is starting out small with each of these three benefit enhancements to ensure that they have the correct protocol in place and they have committees for each, they're working on them closely with their primary care committee and population health committee. So I remember Sarah Berry describing when she was here the last time that they have quite a list of procedures that they're going to go through to ensure that patients who qualify for the next gen benefit will receive it and one would presume they would also have that for the non-attributed labs. But we could follow up to find out what their, they submitted protocols with their next gen application and we could see how those are now rolling out if once their, once their pilots were being implemented. I think that would be helpful. Just to, I would, your team need to get. Yeah, we have the information from families. I've been in a position where a family member only stayed in the hospital for two days, got a lease and then they sort of whacked because they didn't have the resources to cover that we had to stay. So. And I mostly got an anecdotal, the other way where people were discussed were staying in the hospital for the extra days or that they were just covered. Yeah, I think it's good that they're not going to stop there. But I just also don't want people that can't go and pay the bills that are still nursing facilities to be rushed out in the same manner even though it probably is the right thing to do. And then being stuck with a bill that nobody pays. Yeah. One case is required to. This is a tricky one foot in each canoe. Yeah. On the ground. We do have the implementation plans for the waivers. One case required to submit an implementation plan to CMMI and those plans essentially create pilots within the pilot and we can share that information with you so that you, we can even analyze the plans and pull out the information to describe how it's taking place in practice or how it's proposed to take place. Pina, can you, just that last look at that attribution methodology. We were going to have a chat a bit about Seattle markets and those concerns and how we can get there over the next five years. So this is obviously promising that there's a possibility through the 2020 customizable model that we can reimagine our attribution methodology. So I'm wondering if you could just talk a little bit more about the process of timeline and what kind of latitude you're thinking about here. We can, what you're laughing at, we can share it with us. Okay, I'll give it a shot. I think to be frank, we need to convene a process for this discussion and that it needs to be a stakeholder process. And that we don't, we haven't arrived at a timeline for that at this time unless I'm mistaken, I'm looking at Melissa, I'm pretty sure we have not. We have not arrived at a timeline for that work at this time. That work, the scope of that work can be more narrow or it can be broad. I don't think that we need to necessarily be narrow in our thinking. I think that we can take an aggressive look at attribution and the potential ways to think about it differently to increase the scale of the model. We're doing some background research to help us in understanding what other attribution methodologies are out there and also communicating a bit with the MMI about some ideas that they have on this matter. But I think we need to get back to you on the exact process. Thank you. Other questions? I think everybody is longing to be outside and so on. Thank you very much, Yvonne. Comments and questions from the public? The public wants to get outside, please. Yeah, they want to get outside. Yeah, they want to get outside. Yeah, they want to be in bunny. Go ahead. Puzzle? Yeah, I was going to say puzzle and trying to... I don't see this as an apples to apples comparison, which can be a problem because I think it's going to be more of a qualitative, quantitative assessment to actually understand it all. And at the same time, I'm worried that people are going to look for an apple to apple comparison and that's exactly what you can't get. It's like if you're up in the Chittman area, you might be picking delicious apples. If you're down in Windsor County, something like that, you might be talking grainy apples. And the reason I said that is because, okay, it sounds like an apple to apple comparison, but if you're ever seeing a grainy apple and you've ever seen a delicious apple, you're nothing alike. And so that has been puzzled as far as how do you mesh that? The other one is with the attribution, I remember hearing about there's a way that attribution, as much as you can be attributed, there's a way you can then be taken out. That way of taking out, I've never seen fully described in terms of even though it's valid why they may come out, how that in itself affects the performance. And then the other one is co-pays. People that are having their services coronated, our response may seem to us that the co-pay is, if I have enough services being coordinated and accumulation of co-pays, how do I know that's not gonna affect the outcome as well? You wanna take that one, Nina? You've described why I have a job now. I'm just gonna pass it off to Sarah. I think your points about attribution are right on the money, like literally on the money. And I'll let Sarah talk a little bit more about that. And I frankly think we're working on a lot of the answers and you've identified a lot of the challenges that we're trying to address. And we've got much different things that we're counting a lot of times in the numerator and denominator. And so trying to get those aligned so that they make sense is one of the things that we're trying to figure out. So we can at least give a de-graning apple. Hybrids. One of the things that will be really interesting for us to provide and to see at the end of the performance year and then after all the run-out has occurred is what attrition does look like across the three pairs in the programs. The way that people are attributed is basically as rules and things that have to be met in order for them to be attributed to the model of anything that is no longer met then attrition occurs. And so what does that look like and how does it impact on the ACO's budget? Yeah, other questions? Yeah, I see none. Thank you very much, team. Is there any old business to come before the board? Is there any new business to come before the board? If there's not some motion to adjourn? No. I can. You will be second to adjourn. All those in favor sit and talk by saying aye. Aye. Any opposed?