The first item on the agenda is the Executive Director's Report, Susan Farag. Thank you, Mr. Chair. Welcome everyone to our Green Mountain Care Board meeting today. I do have some scheduling announcements. Next week is the day before Thanksgiving, and so we do not have a board meeting. I will let you know, however, that we have a board meeting scheduled on Monday, November 19th, starting at 1 p.m. So we do have a board meeting next week. It's just not on Thursday. And I would encourage folks who haven't already to please sign in, and that is all I have to announce today. Thank you, Susan. The next item on the agenda is the approval of the minutes of Wednesday, November 7th. Is there a motion? Seven. It has been moved and seconded to approve the minutes of Wednesday, November 7th, without any additions, deletions, or corrections. Any discussion? Seeing none, all those in favor, signify by saying aye. Aye. At this point we'll ask Mike and Michelle to come forward. Let's speak up loudly. Anybody in the back here? Yep. Great. Welcome. Thank you for coming. Today we will be providing a review and discussion regarding key responsibilities for the 2019 Vermont Medicare ACO Initiative and the 2019 ACO Budget Regulation. I will say that on the former slide, can we throw a split that she was not able to attempt today? So our agenda is as follows. We have four key sections that we will be reviewing with you today. We will be starting with two proposals for the 2019 Vermont Medicare ACO Initiative, which is our custom Medicare Next Generation Agreement that CUMI has been working on in conjunction with the Green Mountain Care Board. There are two potential votes for consideration. Mike will then provide an update on the ACO Budget Review and Medicare Venture Time Lines. Third, Sarah Lindberg will come up and Mike will review key areas of the Vermont All-Pair ACO Model Agreement, including scale, alignment, and the Medicare benchmark. And then finally we will begin discussing ACO investments and preliminary recommendations. And Mike will provide a preliminary discussion on one pair's operational budget. Now I will turn it over to Michelle and Pat. They're from the Medicare ACO Initiative and an update on the quality framework. The Section 60 of the All-Pair Model ACO Agreement provides a foundation for this framework that we'll be discussing today, namely the section that holds it there for you. As Melissa mentioned, Vermont and the ACO have the opportunity to design a unique Medicare Next Generation Program, which will take effect in 2019. As you'll recall, in July, Pat and I presented a consensus measure that has been vetted by CNMI, the Medicare and the healthcare advocate. The set includes 13 measures, which you approve on July 11th. As a reminder, right there. The goal here is to show that across the care programs and with the measures vetted in the All-Pair Model Agreement, I'll again note here that CAC's measures differ by care, and the ones selected for this particular Medicare arrangement are the related Medicare ACO costs. In terms of access, over the past couple of months, we've brought stock HCA and one care to work into my life as a proposal to be considered for the 2019 Vermont Medicare ACO Initiative. There are two key points to consider throughout this process. First, which of the selected measures will impact payment from Medicare to ACO? And then how will the ACO's performance on those measures impact the amount of movement received? Or does it fund agreement language? It's important to note here that the proposed framework is very closely aligned with the Vermont Medicaid Next Generation Program through DIVA in terms of withhold percentages for and performance in distribution of those funds based on scoring. We'll review some progress to date on the framework as we work to conquer the HCA one care throughout this process and are thankful for their continued efforts. CMMI has reviewed and verbally approved the proposal that we're about to share with you and the next step will be to New York's keeping the boards review and approval of the proposal as well. The framework itself is built off of four key elements. The first withhold percentages for the value-based performance fund. The second identification of payment measures. There are scoring performance on payment measures and fourth distribution of those value-based funds based on quality of performance. And Pat is going to review each of these in detail. Thank you, Michelle, for the record. My name is Pat Jones. I'm staff with the Dream Out Care Board. As Michelle mentioned, there are really four key elements to this framework, linking payment to quality. And we wanted to provide a little more detail on each of those elements. So the first is the establishment of a value-based incentive fund with withhold percentages. And the Medicare proposal that we're presenting to you that CMS has reviewed is very aligned with the Medicaid and commercial programs in terms of how the value-based incentive fund is set up and how it's used. So it's supported by a withhold at percentages that are outlined in the table below. And that withhold comes from the all-inclusive population-based payments that Medicare will be providing to the ACO. So in calendar year 2019, which corresponds with performance year two, the withhold percentage that's proposed is 0.5% of that all-inclusive population-based payment. In 2020, the percentage would go up to 1%. And then in the out years, we've left that open and determined that it would be best to see how the program is going and then establish those withhold percentages closer to the actual time of that taking effect. The general approach of a value-based incentive fund is that the funds are distributed from that fund based on the quality scores of the ACO. And any unearned funds, if they are not distributed in this program, would be required to be reinvested in quality improvement activities to address gaps in care and to improve performance on certain measures. The second key element is really the identification of which measures will serve as payment measures in the model. And this is a slightly more detailed listing of the measures from what Michelle just showed you. The top set of measures in this table are what we would call process or clinical measures, and there are 12 of those. And then at the bottom of the table are the patient experience measures. While that's one survey, and we tend to think of it as one measure, there are actually eight sub-measures or composites. And we are outlining which of these measures impact payment. So in performance years two and three, so that's 2019 and 2020, of those 12 clinical and process measures, eight of them would be linked to payment. That means that how the ACO performs on those measures would impact what percentage of that value based on the incentive fund could that be distributed to the provider network of the ACO. The four measures that are not suggested for payment in the early years are measures that are new in terms of their applicability to Medicare. These are measures that are not traditionally in Medicare-related measure sets, but they're very important measures related to mental health and substance abuse treatment. So the idea is to have them serve as reporting measures in 2019 and 2020, and then in 21 and 22, move those into the payment route. So by the end of 2022, all of those processing clinical measures would be linked to payment. In terms of the patient experience measures, again, there are eight composites there. And the proposal for 2019 and 2020 is for six of those eight to be linked to payment or for them to continue to be payment measures throughout the life of the agreement. And two of the measures would be slated to be reporting measures in performance years two and three. One is the health status and functional status composite that's recommended for reporting throughout the term of the agreement. The stewardship of patient resources is a reporting measure in performance years two and three. And we felt that we would want to revisit that in advance of 2021 to see if that should remain reporting or move to a performance measure. So the upshot is that in 2019 and 2020, there's a total of 14 payment measures. That's about 70% of the total set of measures. And then in the out years, at least 90% of the measures would contribute to payment restrictions. The next area is scoring and how performance is scored on those quality measures. And the way it would work is that each of those payment measures would be scored individually and they would each carry equal weight in terms of the overall ACO quality score. Again, reporting measures, while they'll be reported, would not be scored. Lung care's performance would then be compared to the national Medicare results, the percentile benchmarks when those are available. And the ACO can earn up to two points per measure. The total possible number of points is the number of payment measures times that maximum of two points. So as you can see in the table below, there are 14 measures. So for performance years two and three, 2019 and 2020, there's a total maximum point value of 28 points. In performance years four or five as we add in some of those mental health and substance abuse measures and potentially another patient experience measure, that total would go up to either 36 or 38 total points. Beginning in the third performance year, so 2020, under this Medicare proposal, one care would be able to earn points for improvement over the prior year's performance. But in no circumstance could they exceed the maximum total possible points. So the combination of quality points compared to the Medicare benchmark and improvement points cannot exceed 28 points in performance years two and three and either the 36 or 38 and four and five. And this just shows a little more detail on how performance is scored. So the left hand column is the percentile ranking. So this would be where the ACO's performance on a particular measure falls in terms of their percentile ranking compared to the Medicare benchmark. And you can see that obviously the highest number of points for 90th percentile above that's where they would get the maximum of two points. And I just want to point out that in quality improvement circles 90th percentile is considered to be pretty much the highest achievable benchmark. So they would get the maximum number of points there and then with declining point values as their percentile ranking goes down. And you can see that in performance years four and five, the point values get more stringent as the performance moves down with percentile ranking. And then the next element is how are those funds that are in the value-based incentive on distributed depending on how the ACO performs on all of its quality measures in aggregate. And you probably noticed in the proposal, the memo that you received describing this proposal that there are some excruciatingly detailed tables at the end of the memo. And this is just an excerpt from one of those tables. It speaks to performance year to 2019. The value-based incentive fund withhold you may recall is 0.5 percent. And this excerpt from the table just shows how the funds would be distributed between distribution to network providers and funds for re-investment in quality improvement initiatives. So you can see that if the ACO, that's 14 out of the 28 total points, about half of the payment would be distributed to network providers and about half would then be available for re-investment in QI initiatives. And this very much mirrors what's in the Medicaid contract with the ROT Medicaid next-gen program. And I just want to note that in terms of those quality improvement initiatives, the expectation and what's outlined in the memo is that one care would report to the Green Mountain Care Board annually probably through the ACO budget review process and the amount of dollars that are being used for quality improvement initiatives, what the initiatives are that would be supported by those dollars and the progress that the ACO would expect to be attained as a result of those investments in quality improvement initiatives. So that's the end of my, I'm going to turn it back over to Michelle in a moment, but I did want to just make a couple of key points. One is that there really is strong alignment in this proposal with what is currently in the ROT Medicaid next-gen agreement and also in the commercial agreements. And that is a goal of the all-care models to have alignment across payers. I want to especially thank Julia Shaw from the Office of the Healthcare Advocate Sarah Barry from One Care ROT for their work. We had a series of meetings to develop this consensus proposal. I want to thank Michelle for her leadership in that effort. And I want to emphasize again that CMS has indicated approval for this proposal. Obviously this speaks to the agreement between One Care and CMS. I'll turn it back over to Michelle for some closing thoughts on this topic. So Pat did a really great job with wrapping up. I'll talk a little bit about future and then swap to the decision point. So future work as Pat's movement in her discussion will include facilitation of discussions again between CMS One Care and the HCA. As you saw, some of those both withholds and measures are to be determined in some out years. So we'll have a subsequent proposal to submit to the board and to CMS by establishing those performance year 4 and 5 percentages for the value-based incentive fund and establishing the distribution of those funds based on the quality score. So with that detail, we're seeking the board's approval of those four key elements that Pat went through in detail. So again, the withhold percentage for the value-based incentive funds, the identification of those payment measures from the approved quality measure set, the scoring of the ACF performance on those measures and finding the distribution of those funds based on the quality score and sheet. I should put my water up here. Do you want the questions at now or how it holds together? I think questions on this topic now are potentially low. Thank you. So questions from the board? Yeah, I just had a question. Can you put the timing of things? So if the withhold percentage is 0.5, then when do we actually get the quality results come in to be able to then marry up how much went to each bucket in that example you gave of the 14? It's going to be a summer following the end of the performance year, so late summer or early fall. So that's why we were thinking perhaps the ACO budget process would be a good place to review that since we're here in front of you now. We'd be able to talk about the prior calendar year at this time. That was great. I'm just to get some scale here to turn these percentages into dollars. So for the performance year 2019, do you have an estimate of what 1.5 or 1% equals in that fund? We reserve the right to check on this when we believe it's about 3 million. It's not insignificant amount of dollars. We'll actually follow up on that. I asked a question just to get a sense of, as it trickles through this matrix of scoring, how small an increment does this get reduced to? So that's kind of the core of the question. Any other questions or comments from the board? Not a whole group. I'll just bring the questions and comments. Yes. So I want to echo some of the good feelings. I think if Julia were here, we appreciate the collaborative effort and we did join with the board in one care and the proposal in front of you. But I also do have to say out loud that we will continue as time goes forward to call for and advocate for more stringent measures, more stringent ways of counting whether quality measures have been met and the distribution was. Do you have a specific example of what that might be? I think, so again, we're supporting the proposal in front of you, but as time goes forward, I think the concept of giving quality payments for measures that one care is less than 50% of the national average is something that didn't make sense to us. Or maybe I should say we will advocate for moving to a higher level of quality of comparison to the rest of the country. There's a question for me. Once these are approved, how often can they be changed? Well, I guess technically, I'm assuming that Medicare will continue to do an annual type of agreement with the ACO. So I guess in the most technical sense, you could, you know, see some changes in quality. Michelle and I both mentioned there's a couple of areas where for some of the reasons that Mike just indicated, we, you know, we wanted to hold off, like for example, how much of a withhold should there be? We didn't have consensus on that and felt it was important enough to hold off on making that decision. We were comfortable nailing down in 2019 and 2020, but we would love to come back together for 21 and 22. That's an example where things could change. You know, then obviously if the science changes around a particular measure, we would want to look at that. In general, the idea of trying to keep measures constant so that the provider at work has some focus and knows what to work on and we can really engage in some of that over time improvement is valuable, but if a measure is considered to be no longer a good measure or a valid measure, that would be something that we would want to revisit as well, I should think. But, you know, this again would go into the agreement between one care and CMS as far as I know, those are still annual agreements. So it's your vision that would only be approving it from 2019. Our vision is that you'd be approving it as proposed and so there are some decisions that are across all four years. For example, a lot of most of the measures are proposed to be payment measures across all four years. And some of the decisions are two-year decisions like on the percentage of withhold. We would expect to come back to you on those areas where we did not make a recommendation, but for the ones that we did, we would not anticipate revisiting them unless there was a compelling reason to do so. Other questions or comments from the public? Is anyone ready to make a motion today? I'm ready to make a motion. I would move approval of the quality framework proposal, including the components that were outlined by our staff today. Seconded. Any discussion? I think the only thing I would add is I think that as we often hear when we have provider panels, the quality measurement structure is an area where there's a lot of tension, I think, between providers who want fewer and consumer advocates who understandably want more. So I think trying to balance those two is a tough job, and thank you to our staff for working through that. Seeing no other discussion, all those in favor of the motion, signify by saying aye. Aye. Any opposed? Let's do the view of the second proposal. Can you speak up a little bit? Yeah, sorry. Thanks. I'm going to speak with you about the second proposal with respect to the 2019 Not Medicare ACO Initiative. It's a continuation of the discussion we had months ago at this point. So to remind you, on June 25th, 2018, after discussions with OneCare about what kinds of changes to the Medicare or the Medicare next generation program might be feasible for 2019, OneCare's intensive memo requesting several of Care Care's operational changes that they wanted to see in 2019. On August 1st, we approved the plan to send OneCare's memo to CNMI with commentary about what the Board thought of each request. That memo didn't get sent because OneCare indicated they wanted to make some changes to those requests. And so that's what I'm here to talk to you about. One of them, the changes that are relating to those two red highlighted bullets there, governance and beneficiary motives. The changes that OneCare wants to make to the governance requirements of the Medicare participation agreement is that they want to change it to say that the governing body of OneCare must be comprised of 75% participants or preferred providers and preferred providers, what are designated representatives in its network. The red language about designated representatives is the language OneCare wants to add from what the initially requested, but it's the language that is actually in the Medicare participation agreement currently. And keeping it there would mean that hospitals, designated agencies, home health agencies, independent primary care practices and other participants or preferred providers represented on OneCare's Board of Managers could designate someone outside their organization to serve for them. It is playing versus currently in the agreement. It is not inconsistent in any way with Rule 5 that governs ACO and governing body composition. And so I don't see the problem with accommodating this request. OneCare, like I mentioned, also wants to make some changes to the Medicare beneficiary notice and patient fact sheet that they want to propose to see on the line. They want to improve the readability of those materials based on input from Medicare beneficiaries. You should receive a copy of the revised materials in your packets. Essentially, the new version still covers the same basic topics as the last one and has the same basic format but is written in a simpler manner. CMS will still have to approve these materials and I believe that they will require some changes to be made. For example, I think they will require that language to be added about the Medicare benefit enhancements that are available through the program. However, since it's a change to what we are sending on to CMI, I wanted to bring it to you to get your order okay before we send it. So in terms of decision points, I guess the question I will put to the board is may we send OneCare's realizer memo to CMI with the new governance language for the new beneficiary notice and patient fact sheet? We have an answering question to you. Let's start with the question. So I'm a little bit concerned by opening the door to designated representatives. Maybe I would feel more comfortable if you could give me some real good examples of a specific situation. Specific situation that's happened that you could envision happening. I could envision a decision. So OneCare's board managers certain provider groups elect representatives. And if, so for example, designated agencies, they wanted to designate someone who wasn't a designated agency to serve as their representative on the board of managers, that would be what this would be. Is that helpful? So I can see one thing. An employee of the designated agency would be saying that they basically designated anybody that person wouldn't have the knowledge. So for like an association president of that Q&C association, for example, it might be someone that they would want to designate, it's not. But if they're an employee of that little front, they've really just been for a confirmed provider. You have to remember that these terms are defined by Medicare. So the preferred provider has a specific, the example Mike was giving, which is the designated agency that participates in OneCare may say, hey, I want somebody from my state to sit on the board of managers because they have a statewide perspective. I just have a perspective of my specific area. That actually would provide better representation to efficiencies across the state. You can see why that would work, but I say it's not a preferred provider because they're not actually a provider, technically. And it's my understanding that this is actually a line of what's actually the language in the agreement. So we're trying to align some of the agreement with... The second bullet there is the language that is currently in the Medicare participation agreement. And I was just trying to highlight that this is not new language, it's language that they originally deleted, I think, in our rule five on this specific subject, allows for designated representatives of providers to serve. Any other questions or comments from the board? Yeah, I have a little bit of the same concern. You started out with Kevin. I just... Can you explain a little bit of the history as to why this language was added back, what that discussion was about? It was adding flexibility for providers to choose who they want to represent their interests on board. So could a designated representative be a lobbyist? I have a good question. I don't think that's the intent.  The network comes after designated representatives. But if you're uncomfortable with this, I can go back and get clarification on this specific issue and test some possibilities with one care. My concern is that the language could be great, but sometimes language like that is a kind of an awkward moment of having the better knowledge at the table. I could see where it might not be that helpful to have people that are kind of paid lobbyists in a management position. That's so important to help care reform. Can I just say, as far as a legal read on this, for one thing, the consistency kind of gives us some credibility and it allows for flexibility, but it doesn't mandate that. This assumes that out of the... when read in the full context, this is the same type of language and it allows a designee in the network, too. We can look at it again, but as far as a legal read on this, I don't think it's the creative parables that this thing could just designee somebody out of nowhere. What would the threshold be for designation, Judy? What would the threshold be? Well, you have the ability to designee hearing officer for hearings and I guess it would be assumed that you wouldn't just pick Pam Davis or someone out of the audience and we'll do it the other way around. I'm hearing officer. So, again, I think it would have to be reviewing the context. If you want the board, if you want the staff to look at this more in context, but I do think that it's good to be cautious, but I do think that some of this language has been vetted and was consistent and it's not that it's getting added, it's getting put back in as far as that goes. So, I understand the concerns, but I think that looking to the worst possible extent probably isn't needed and we can look at this in context of the agreement by now. My understanding is as it reads and as it was omitted and as it's consistent with other language that it's a relatively harmless and consistent with the agreement replacement of the language. Do you have other comments or questions from the board? I'll open it up to the public for comments or questions. Yes. To clarify it, is this just on the governance or are we talking about the new patient fact sheet and the other materials too? So, I believe we're talking to some other members right now. Your question is on the other side.  I can follow up on your concerns about the others. I actually think that would be welcome. I think we should go over here. The board questions or comments on the beneficiary notice and the fact sheet. I thought that your ability to identify that would be right. Thank you. Any public comment or questions on the fact sheet? Yes, Susan. Susan Aronow from the Vermont Developmental Disabilities Council. There's some language on the fact sheet. There's nothing in the fact sheet that would tell a person who's been attributed to an ACO what that means to them. There's some language on the fact sheet that says how might one care benefit me? And there's some language there that one care might benefit someone. But I think the corollary is equally true. It needs to be explored. How might I benefit one care? One care is going to receive a monthly payment on my behalf no matter what services I use or don't use. One care might receive a quality payment on my behalf if I lose weight or quit smoking or do something else. One care might benefit from me being attributed. And I really do believe that people have a right to know that. To know that they're I really need a better term for this. If anyone has a suggestion please email me. Attributed lives are essentially cash cows. They earn money for one care. One care gets paid not just for Medicare for their medical care but for the Medicaid ACO they also get a $6 per member per month payment. So people are generating funds for one care but nothing in the notice tells anyone that. They have no way of knowing. Nor do they know that they are entitled to other benefits the enhanced benefits that one care has been applying for permission to run and running or piloting or not running but no one knows that they don't have to stay in a hospital for three days if they're in attributed life. And one care never has done anything to tell them. So really I don't think the fact she goes far enough as far as informing a person just an individual for a minor what it means to be in attributed life. It doesn't tell them anything. It's kind of a fine line that you have to recover because if you make it into a book you won't read it at least I wouldn't but does the Health Care Advocates Office want to weigh in on the faction? No, we don't have a comment at this time. Okay. Does anyone else have a comment? Question? Seeing none. Would you want an individual motion on this or would you hold on this until we're ready on that? I would just hold this all. Okay. Now we're moving on to the ACO budget review and Medicare benchmark timeline and the vision we had to make to that timeline. This first slide is just showing you what has been completed today. Starting on 724 with the issuance of the ACO budget guidance and the reporting manual. One care area submitted to the budget on October 1st. Team C staff and the Health Care Advocates sent a first round of questions on October 10th. One care was funded on the 16th. We had the budget hearing on the 24th. We sent as well as the Health Care Advocates on the 29th. And then one care responded to those second round of questions on November 5th. And this is our tentative timeline for the remainder of this process. So we're here today to give some preliminary observations as best we can given the state of information. On the 28th we are tentatively on schedule to make some recommendations to you on your Medicare benchmark and ACO budget. December 12th we have scheduled the case 1128 doesn't work and if it does, then to follow up to the extent necessary and have potential votes on both the Medicare benchmark and the ACO budget and then kind of the last early date we can go with this is 12.17 a Monday to finish this up. And once we do finish it up we need to submit the Medicare benchmark to see on the mind for approval of the ACP. Any questions on that? I had a correct election some while without this meeting. Is that then I'm sorry. It was we did have that team on there. One CARES Board of Managers is meeting on the 18th and so we scheduled for the 17th on the day versus the Wednesday so if we approve the Medicare benchmark we're going to review and sign ourselves reasonable. Okay, great. I'm going to just show some charts remind us about high level requirements for the model gosh this color's got a little blood out I'm sorry about that but the first thing I wanted to kind of orient everyone to is the different populations in play when we talk about the all fair model so the faint line at the very top is the Vermont population so anything that is dashed would represent estimate or projection I think solid is what's in the books so far so for instance we won't get the population estimates for Vermont for 18 until the spring they kind of shave a little bit off these days so that line might go down a smidge after those come out and then the darker purple line below that is denominator we're using when we talk about scale so what we are targeting for getting people in the model is not the same number as we count for the total cost of care and that is the fainter line below it and that is the population that we're using we calculate the total cost of care so they used to be pretty well aligned but then this guy called Alvobay went to court lost so self-funded employers who aren't a governmental plan and get an exemption no longer have to submit their claims to vcures so that is what that big decline between 16 and 17 is so as a result this is the number that is working in terms of getting people in the model but this is the people for whom we have claims in vcures that are eligible for calculating these performance matters the scale target for 2019 is 50% so about McWay from there is where we're trying to be for 2019 as you can see the attribution for the asio is growing quickly we are climbing at a fast rate which is what you want to see so this again is just people prospectively aligned to one care and then the smallest line down here is those who are asio-assertive Medicare beneficiaries so for the first few years of the agreement any Medicare performance metrics are just tied to this population and eventually it extends to the Medicare population at large so these are more estimates so on the left hand column are coming from the numbers we submitted to the legislature about how we thought we were doing on scale these numbers will be revised as newer data come in but at that time we were estimating about a 36% performance around the Medicare target and we should have been at 60% and the all pair we estimated about 20% aligned to the asio when the target was 35 so again a lot of till days meaning a lot of uncertainty for 2019 hasn't happened yet we're thinking we're probably going to come in around 50% for Medicare where the target is 75% for the Medicare scale target and about 35% for the all pair where the target is 50% so basically we're about a year behind when it comes to performance on the scale initiatives a couple of populations to keep your eye on the self-funded numbers in a lot of ways the fuzziest and that goes back to that decision we have to do a lot of estimating to figure out who's not there it's definitely a known unknown so it's one of the least certain estimates we have and the other thing this guy is really creeping up in recent years that would be the Medicare Advantage business we're observing a pretty steady skate increase north of 10% of the Medicare population at this point why that's notable is it tends to be a healthier population and for the all pair on all purposes they're going to count as commercial so that's good risk kind of going to our commercial market which will wash out in terms of the all pair performance but might make it a little tougher on the Medicare side of things for performance measures so at the end of the day what we're on the hook for for the agreement for financial performance is whatever the all pair for the foster care is in 2022 compared to what it was in 2017 and then we compound that by taking it to the fifth power and take away one so basically we can see if we're on track or not to get there but we're it's a very long term goal it's over the full course of the agreement also bear in mind that when we talk about the total cost of care which I always joke should be the sum of some care we're not thinking about things like dental pure dental coverage retail pharmacy stuff like that and then there's many services provided through Medicaid such as home and community day services which are not included so at the end of the day only about half of the Medicaid spending is actually included in the total cost of care so when you see APM total cost of care metrics they might not match other performance measures of cost there's usually a good reason so ask me okay and then we can talk about the target so again we're on the hook for this compounding target to date and the agreement states that the target is 3.5% or less over the course of the agreement however a corrective action is not triggered unless we exceed 4.3% and again that's the compounding growth rate so we're talking about starting performance year 2 so we'll take the growth rate in 19 compared to 17 take the square root we're going to see where we're at and then in terms of how it's calculated the data are messy but what we try to do for the clean side of things is we look at the data we have available in vcures we try and figure out what the primary payer is for the month I shouldn't say primary payer type so if someone has coverage from Medicare and Medicaid we're going to count them as Medicare and then we'll take all the primary allowed amounts from that primary payer paid in that month why that's important is that it's going to include both what the insurer paid and the members responsibility so if any subsequent coverage helps cover the members share it's still in there it just didn't actually get paid by Medicare or the member so we still have the full cost it's allocated based on the primary coverage for the month and I think that's about the best we can do given the data sources available to us then on top of that we include a non-claims component in the total cost of care so that includes things like the population based payments given by Medicaid, savings or losses achieved by the ACO as well as the blueprint and community health payments so it's pretty explicit in the agreement any savings or losses by the ACO are added to the total cost of care or deducted from the total cost of care so that is incorporated into the total cost of care when we're calculating that alright Medicare so again for the first few years of the agreement when we talk about the Medicare total cost of care we're really talking about the subset of beneficiaries who are attributed to the ACO and again this really is a compounding target and we can only look at how we're doing to date but the agreement says that our target is 0.2% points less than the national projections for that same compounding time period and in here the corrective action will not be triggered unless that calculation were to exceed 0.1 of what the national projections were but it's a little bit funny we get our target well in advance the call letter comes out each April we know where we need to hit but then we don't need to actually assess our performance until well after the year is over so for instance for the current performance year 2018 we need to get 18 in the books let the claims settle out figure out the savings before we know what the total cost of care in 18 was for the ACO beneficiaries then we get to compare that to like for the same provider list in 2017 and that's the ratio we're going to use for the 17 to 18 growth rate we'll have to do a similar calculation of 18 over 19 take those, the product of those and we'll spur a route and then we'll get the compounding target today and that's what we need to see is 0.2 less than those national projections so essentially for 19 we probably won't know where we stand until the mail third quarter of 2020 it was fun isn't it alright so let's go to the party click like so again this comes from what they call the call letter it is what Medicare uses to try and get commercial insurance to participate in Medicare Advantage so as part of that letter each year they try and project what spending looks like and they divided that into what they call traditional fee for service in the Medicare Advantage population and so they further break those estimates down into two big populations there's almost 99% plus are aged and disabled in Vermont so that's kind of your business as usual kind of Medicare and then there's the end stage renal disease and while they're a fraction of a percent of the population care in Vermont they're quite a bit more expensive as a population as you can see so they do separate projections for those two beneficiary groups then they blend those two together in order to get a blended growth rate and the only time that really comes into places when we talk about trending savings or losses forward in the benchmark calculation so just based on the call letter the annual growth rate from 18 to 19 in the 19 call letter it was 4% for aged and disabled 3.3 for the end stage renal disease and that blends to the 4 usually it's pretty close because it's so much more of the population so then we take that and then each of these we multiply by 3.7% because of the floor we use 3.7 you know that's the first term in the equation which compounds to the 3.9 3.5 and 3.9 so again at the end of 2020 we'll have to take a look at everything that's happened to date and see how we do compare to the targets great Medicare benchmark so again the benchmark is really a financial target that's set for the ACO and it's basically a combination of some sort of estimate of spending in 2018 based on the provider list coming up in 2019 we multiply that by the anticipated number of beneficiaries in the upcoming performance year and then this is the trend factor that is decided on by the GMCB and that's what comes up to the Medicare benchmark and once we have those set for the ESRD and the Asian Disabled populations then we have to then add on in savings realized by the ACO or deducting losses by the ACO and similarly again on the all payer side we're doing similar stuff for adding blueprint payments and that in their life for commercial payers so it's trying to get the full picture of spending if that makes sense that was nice I had oh one more okay oh I just said this though so oh another thing so 19 due to the risk arrangements elected by the ACO in 2018 anything that happens plus or minus they are expecting savings they're only eligible to keep up to 80% of the savings the rest goes back to Medicare and that was due to some risk protection that they elected and yeah just that you know the savings counts as spending for the total cost of care calculations just want to make sure that's on our minds alright thank you so Sarah talked about scale and I wanted to go over with you the scale target ACO initiative requirements so in order for someone to count someone who's attributed to an ACO to count for those scale targets they have to be treated under what's called scale target ACO initiative and there are four requirements set out in agreement for what one of these issues is first they're actually possibly going to share savings for team goals related to quality of care for utilization second the ACO's shared savings must be at least 30% the program doesn't have to be a two-sided risk model where the ACO's at risk for losses but if it is then the ACO's risk for shared losses also has to be at least 30% third the services the ACO's financially responsible for must at least include services comparable to all-payer financial target services for Medicaid and commercial insurers that and self-funded that that is a heat hospital patient and outpatient care post acute care professional services and durable medical equipment the ACO's benchmark shared savings, shared losses or some combination has to be tied to quality of care the ACO delivers health at its own which is basically the value based incentive fund proposal that Michelle Pat discussed with me so I wanted to talk about what we can gather from the budget submission in terms of 2019 programs and what they may look like in terms of these requirements so as you know for 2018 there's a Medicare program, Medicaid program Blue Cross Blue Shield QHP program and EVMMC's under health planning program we presented earlier in the year on how these programs we thought for the requirements for the ACO skills are initiative CMS is going to have to compare with that assessments we reported them next year on this so in terms of 2019 changes to these programs programs are not finalized but one care's budget suggesting may change in the ways that we show here with the Medicare program one care's budget is built on moving from 80% gain loss share to a 100% share and then as Pat and Michelle talked about the Medicare program will likely include a quality withhold that's meant when we're tying financial performance to quality performance with the Medicaid program one care is budgeting a 4% risk corridor whereas the corridor this year was 3% one care is also budgeting an increase to the percentage of the benchmark withheld for the other basis in the current with the Blue Cross program there's a possibility that one care would not be responsible for non-special pharmacy in 2019 which is not an all payer financial target service and then with the existing program the budget indicates that in addition to expanding if may move from shared savings to share risk with a corridor of 6% and a risk gain share of 30% so we do that 30% requirement for scale target usage the basic takeaway is that none of these changes we think would need to disqualify those programs that are existing in 2018 from being considered scale target issue with these changes one care's budget describes that they're working on a potential new self funded program which we're still very early in the negotiations and it's really not described in enough detail to say whether it might qualify as a scale target issue although one care is pretty clear that it intends to develop the program as such if you'll recall last year we were in kind of a similar situation where we the Blue Cross Blue Shield program and the UVMC program were not finalized around this time and the way you guys dealt with it in the budget order was putting a condition in there that one care had to come back similar written report demonstrating to the satisfaction that those programs did qualify as scale target ACO initiatives so I just wanted to remind you of that and maybe give you this summary with in the context of all fair model of the American requirements all fair model agreement also requires that scale target ACO is reasonably aligned with the Medicare ACO program on things like the shared alignment methodologies ACO quality measures, payment mechanisms and risk arrangements there didn't have to be complete alignment but we will need to justify material differences or present CMS with a plan to bridge those differences we can't justify any issues with this we asked the Medicare and the budget about how their 2019 programs align and realizing that these programs are still being negotiated and trying to put the major takeaways here so one care contemplating changes to the alignment for attribution methodology used in the Medicaid program potential changes including expanding the definition of primary care providers including additional codes to the list of qualifying evaluation and management codes that are used to attribute people extending the claims to the back period from two to three years and then there are no changes to attribution methodology anticipated for the other payers quality measures Pat and Michelle talked to you a couple of times about the Medicare measures and all the work that's been done to get reasonable alignment of quality measures across payers in terms of payment mechanisms 2019 looks like it will be a continuation of 2018 where the public payers will be utilizing the all these population based payment mechanism and other payers are continuing to pay for service and get everyone care that a PNPM amount to support its population health management. One care explained Blue Cross has been unable to implement the AIPDP with their claims processing system as you know the AIPDP basically allows one care to be exchanged for hospitals and it's a significant risk management tool for them. So this is a potential alignment issue that we may have to address in our report and we may need one care's help in doing that in terms of risk arrangements all the risk programs that one care described in the budget are symmetrical shared risk arrangements for the same sharing percentages and caps applied to both shared savings and shared losses the exact percentages from care to care but those are tightening up this year as the Medicaid risk corridors expanding from 3 to 4 percent and the sharing percentage in the Medicare program is budgeted to increase from 80 percent to 100 percent like is in Medicaid. With respect to the services included in determining shared savings and losses as I mentioned there's a potential non-special pharmacy to know whether you're doing a cross program but they're a bad thing it's in none of the other programs so it will create more alignment. Questions on standardized portion of this? I just have one question about the attribution of biology changes in Medicaid. You mentioned changing the ENM codes expanding the list of fall buying primary care providers expanding the look back I'm trying to get a sense of what is the estimated impact of those methodology changes and I was looking back on Sarah's table for Medicaid I know you have a tilde for the 140,000 there but I'm wondering you know is that accounting for that change in attribution methodology I would think that caseloads are falling so that that never would have gone down but then if you're changing attribution to potentially get more Medicaid patients in that would make it go up so I'm trying to figure out what that effect is do you have a sense of anybody? I don't have a sense and I don't know whether those estimates well I don't have a sense of what we can check with diva my sense is that the main driver of the increase in Medicaid attribution is that that but I was looking at the 136,000 APM population from 18 to 140,000 I recognize that the population started in a scale target initiatives went way up because of the hospitals but I was also thinking just the baseline population I'm trying to figure that out I gave the drawing that to you we could ask diva to tell us what fantastic and they're coming on Monday, so maybe all of us again on Monday there's also a lot of disruption that happens when you're in first so that's part of your penis okay great and also I was just wondering how actually this is on that same table there the commercial self-funded I'm just I am trying to figure out how do you actually get that estimate given the GOBE decision given how are you figuring out what is the potential population there and also just wondering yeah I think the previous estimate was a little hot so that probably will be adjusted when we reach these numbers but the other yeah so the other primary source we have for this information is something called the annual statement supplemental report so that's something that's tied to the annual statements that insurers have to file so there's people that have to file statements that don't have to submit their claims to E-Cures we're also trying to get a better sense the vendor collects our claims data so everyone has to register doesn't matter if you have to submit your claims but as part of that registration process they're asking for the full Vermont Book of Business and that will give us a lot better way to get that estimate as a follow up on that do they break it down by hospital service they when they're doing that file they don't have a DFR oh gosh no and honestly I don't know if that would be relevant for them it's harder it might be helpful yeah and honestly I think what's important to an insurer is the citus of the business like where is the contract so residency is kind of not as important in their world so those filers just take a percentage of their total book of business to estimate I don't think it's the strongest estimate in the world but it's the best we have so I wouldn't necessarily put a lot of fake in any word to break down no thank you yeah no problem other questions Maureen two questions first have we aligned on what the starting point is for the Vermont hospital foster care in 2017 we're still completing the validation so we should have that on bear sure I was hoping to have it for today including historical look so you can see what it's been looking like by bear type over time and then when you talk about the corrective action for Medicare which is not to exceed 1% of the national projections how does it factor in that we started off at a higher point the first year so as far as accountability goes that 3.7 is set in the equation so that is the accountability terms yeah okay other questions we want to talk about who cares in the estimates hold on I wasn't going to turn it over I'll look at first because I didn't think there was any decision point here for 98 apparently Susie does have a question so let's stay on topic and go to it we just have a question we'll go back to that chart we're just discussing in the case of 26 when you discuss the commercial Medicare advantage and the increase there this is really just a clarification my understanding is that Medicare beneficiaries who sign up for insurance plans are not eligible for attribution so today since there's no Medicare advantage plan participating that's why if for some reason they contract an ACO they would be but yeah it's just a lack of participation that's the only thing that it's not that they're ineligible and that's why they account for scale do you have any trends I was really surprised because my understanding was that people in Vermont use Medicare advantage plans so do you have any numbers or could you recommend where I might be able to find like how much Medicare advantage use has been increasing over time in Vermont year to year check out the Medicare enrollment dashboard it's amazing it's really creepy we've been quite an anomaly to date in terms of our penetration rate we've been under 10% for a long time so sorry but yeah as of late and I think there's been something targeting of Vermont when I listen to the radio anyway I hear quite a few advertisements for it now we'd like to move on to talk to you about Medicare's 2019 investments and early basic financial observations starting with investments and we thought we would try to pull up the statutory budget review criteria that relate to Luicio investments has a lot to do with model care many of these criteria like strengthening primary care incorporating community-based providers are also what I just wanted to note found in the statute that the first consideration here is how the ACO is reducing duplication of services and integrating with the blueprint for health and its regional care collaborates the rest of the criteria relate to the extent to which the ACO provides incentives for investments in primary care social deterrence of health and incentives for integrating community-based providers and preventing and addressing the impacts of adverse childhood experiences I did want to note that no use of deterrent incentives and that may be something you want to think about as you're thinking about how the ACO is doing on these criteria we are certainly looking at the ACO's actual monetary and non-monetary investments but I think you also consider the incentives it's creating for example the ACO's overall risk model the hospitals are on the look for above-target spending on the local population and the cabitator payments that is making into hospitals can I think be thought of as incentives to for example integrate with community-based providers or as we saw with the rise in T-related investments in the hospital budget cycle invest in social deterrence health I also just wanted to note that there is a fair bit of overlap in this some of the things that the ACO does relate to multiple criteria for example one care plans to continue the blueprint for health PCMH payments and the community health team block payments and it works closely with the community health teams this could be seen as integrating efforts with the blueprint and its regional care collateral that we see as an investment to strengthen primary care and it also could be considered as integration in the ACO's care model so this chart as mentioned the legislature provided statutory requirements for the board to consider when reviewing the ACO's budget and one care investments are seen in programs development and financial investments to address their population health outcomes one care develops their investment priorities through their finance and population health strategy committee and then they're approved by their board of managers so we're showing what we approved last year in the 2018 budget cycle and what they submitted in the 2019 budget cycle last year they focused their campaign payments to primary care and the blueprint and the continuum of care to provide additional support for providers this year they have several new programs which I'll talk about in a moment and of note most line items are increasing from year to year and that is mostly due to attribution because it's tied to the PMPM for that attributed life and we'll note that the primary prevention line half way down was at 1.5 million and this year it's slightly lower and that is due to one care adopting the Rise Vermont program as their own and incorporating those staff into their operational budget as well they had the regional clinical collaborative representatives in that line item and now it's broken up this year as well to make it easier for all to read so I wanted to highlight what some of their 2019 new initiatives are or expanded initiatives they have their comprehensive payment reform program that they offered the three independent practices this year testing it out with them and they provided a preliminary report to the board in June which was showing that it was going to be a successful pilot and they offered it to other entities this coming year that Michelle will speak about in a minute they're also piloting an initiative for independent specialists to test one or more pilot programs in this coming year they have several new adverse pilot event pilots that will discuss later in the presentation they also have a community based innovation fund initiative where communities will be able to apply to them to test out based programs that could be spreadable to other communities and they're contracting or through Medicaid they're developing an accountable community for health pilot where more provides in the community would be accountable as well as the geographic attribution may be applied, methodology may be applied we're actually interested in having Medicaid speak to that at some point either on Monday or when the project has been developed in the future and then finally as we heard earlier this summer from Rise Vermont and OneCare that they are expanding to a statewide collaboration which I will speak to a bit later in the presentation as Mike mentioned there's statutory criteria outlining the blueprint for health sort of so OneCare built their model upon the existing blueprint for health CHT and community collaboratives OneCare, OneCare is continuing those PCMH payments for Medicare lives and the CHT and SAASH payments as well I'll note here the complex care permission program is designed to enable providers across the healthcare continuum to better manage the care of the highest risk payments this is also done through a PMM model there's regional political representatives and they're identified and contracted with OneCare Vermont for about six hours a week in each health service area or their local community and they participate in those local accountable communities for health meetings I'll note too they're spending their CPR pilot that comprehensive payment perform payment program they're adding at least two more practices from 2018 to 2019 and this expansion is for qualified and independent primary care practices that participate in all three payer programs including commercial programs the program provides additional investments and resources to support the transition to a value-based payment model the specialist program that Melissa mentioned earlier OneCare intends to design and implement one or more specialty pilot programs that will focus on populations of rising in high risk or time near access to care and connection between primary and specialty care would better support the patient's needs on this slide in terms of indirect investments it's focused on providing tangible data on cost utilization and quality on a quarterly basis in each HSA with OneCare reporting on six clinical priority areas these reports are provided to those regional clinical representatives who then kind of disseminate the information in their communities and are able to use that information for quality improvement there's also been a continued effort to reduce administrative improvement through the Medicaid contract for removal of prior authorizations additionally as Pat and I described earlier and as Mike has mentioned there's been extensive work with HTA OneCare to develop and implement a modified next generation Medicare program for 2019 the reduction in measures from the Medicare Shared Savings Program is substantial and it allows for much closer alignment between all of the payer programs for community provider investments Mike also mentioned this but you'll notice quite a bit of overlap here from the previous slide with those direct investments but it's important to note that they're not just to primary care providers there are several initiatives that provide payments to both primary care and other community based providers for example as part of the complex care coordination program the community support care coordination payment can be distributed to home health designated agencies or area agencies on aging if the attributed life has designated them as their aged care coordinator in addition there's a one-time patient activation payment available to community providers supporting those patients at the highest risk month is a one-time manual payment and then there's an additional PMPM that gets added up for those patients new this year OneCare has proposed including innovation funds that would support innovative other programs that align with the clinical priorities of the ACO the goal is to identify programs that can be easily replicated and sustained across other communities for indirect investments to community providers there's been movement towards implementation of the next generation Medicare waivers for example SNF 3-day rule waiver is currently in action in Middlebury and is proposed to be started in the Burlington area there's been work done between care coordination programs and designated agencies as noted here to develop and implement the 42 CFR Part 2 consent form process for care navigator and this will allow access to pertinent medical information for those attributed lives with mental health or substance use diagnoses also in Care Navigator expanded patient educational resources are available and those topics include things like chronic disease, nutrition and other available support services for the last portion of the program there's been a series of ongoing criteria that be examined it's regarding one pair of Vermont social determinants of health and adverse childhood experience investments so I wanted to level set what social determinants of health is defined as the healthy people 2020 framework social determinants of health include education, health and health care their social and community context economic stability, neighborhood and built environment examples of those include stable housing access to health care access to healthy foods exposure to violence and so forth so as you'll see the PMPMP payments that Michelle discussed are mentioned here and they're providing extra support to primary care and continue to allow room for the providers to begin to identify social determinants of health one pair is adopting a food insecurity a statewide tool for the network to use food insecurity is one of their key, six key priority areas and so this network tool could be used to identify whether there is good security within a community and then that community could work to identify how to improve it one pair has also adopted Rice Vermont as a primary prevention program to address the health of the entire population they adopted the pilot from Medical Center and they've expanded from 8 to 20 communities in the state over the past two years we noted actually in the hospital budget process that one pair was matching if a hospital put forth 35,000 one pair would also match that to support their hiring of a coordinator for that community and one pair is offering small amplifi grants to support communities to tailor that Rice Vermont program to their own community so there are common measures that Rice Vermont focuses on so a number of these measures look at increased access to healthy foods and then they're also looking at the downstream effects of chronic disease so finally in regards to the younger cohort of one care they're developing a pediatric risk tool for practices to use which would enable that practice to identify their rising risk families they're also designing a shared care plan for the pediatric population that they could use in concert with that and then finally they mentioned that they're working in collaboration with EDH on a new program called Dulce and it is where primary care clinical sites can proactively address social determinants of health and promote healthy development of infants from birth to six while also providing education and legal support for those families and there's a pilot in LaMoyle County currently that they're examining the potential to scale up to other communities thus far what kind of recommendations will you can you expect us to provide regarding the ACS investments in population health first like last year we plan to recommend that one care's population health management programs be funded at a certain percentage of their overall budget we would also recommend a certain funding requirement for a session so that they don't get lost in the overall ratio of the payments out to communities we'd also like to recommend a final full year quality and financial report on the competition pilot for independent primary care practices the report that we received midway was preliminary and we'll be receiving a preliminary quality report so we'd like to look at those in concert with each other with the new specialist payment program we were considering recommending an implementation and evaluation plan to examine the goals that one care has stated that they'd like to increase access to specialists improved quality and facilitate person centered care and so we'd like to know how they're structuring the pilot to achieve those goals and work with them to monitor it we also mentioned earlier that one care is considering testing out how to implement a variable way to distribute their value based incentive fund policy to primary care and so they stated in their budget guidance that some portion of the distribution would be more closely tied to practice level quality performance and we would possibly recommend that you require one care to update us on the progress of that and then finally another recommendation would be to have one care specialist with their 2019 clinical priority areas we requested those and they explained in their budget submission that they'd be engaging their network in the final quarter of 2018 to review and discuss data in their clinical committees in the first quarter of 2019 which is due to what that's when the data comes in on due to data lag so we would very much like to receive those by the end of March in 2019 so this was Kelly's slide but I'll do my best here you know just showing the admin expense ratio for one care 2018 approved budget 2018 projected and then 2019 budget as submitted the kind of highlight that Kelly had here was the expense ratio projected in budget for 2019 at below the approved 2018 level and then population health management and payment for form spending as a percentage of revenues ratio there for the 2018 budget 2018 projected in 2019 budget as you can see there the ratio fell below the required level for 2018 projection one cares come in and explain that what that is due to initial high initial attribution to AMPA for some of the population health management spending I do think we should we didn't work this out but have one care come back next year and deal for a recap of their 18 actuals for us and then the last kind of bullet here that Kelly had was that the salaries and benefits expense line in the budget increased 34.7% from the 2018 budget to the 2019 budget and a large part of that is one care bringing staff in house as well as staff additions to reflect their growing mental what was the justification for bringing it in house from what I would understand it was a pilot in one community that over time had shown success and the board of managers or who must have decided they wanted to adopt it as a statewide program we could have one care provider written justification if you would like but that would be the only way for them to feel statewide okay I'm curious because other companies have had programs similar to the Rossville model so for example, while it has health trust I mean that it takes on a bigger role in attributed lives that somebody could be transferred through one care to house similar to what's happening with rise of Vermont in other areas or Vermont good question I don't want to ask them but I can move to next steps or take questions on this section of the presentation that you prefer let's take questions any questions from the board a couple Tom? so I'm just trying to tie a couple of things out here on the table that you have on the screen now it says that population health and payment reform spending is 3.1% and so I'm going backwards to the chart to I don't know what page it was 2018 and 2019 on camera population health investments at $27.29 million so under 2018 approved so now you're looking at 2018 budget projected and those items are down to 2.3% and so there is the variance between budgeted amounts and projected amounts apparently and I'm just wondering how those two tables relate to each other yeah we do include the budgeted on this table we could easily do that for you that would be helpful to that too because it looks like it would be a cycle now that's not being spent 2018 if we're dropping from 3.1% to 2.3% unless the revenue based denominator has changed a lot which I don't think it has I think the revenue based digit it did change so that percentage change might be attributable to the revenue percent change as opposed to the change in asset spending yep I think this is probably a combination of those that we can and one more as you know in the discussion when I first kind of saw the per member per month growth rate of Medicaid for 2019 projected over 2018 actual I think was like 1.5% and that seemed low to me and you folks appropriately made the point that here is also additional spending that is driven by Medicaid and so you really have to kind of include that in it and I think that's a fair response but is it possible to get down through these two columns and attribute where the funding source is for each so that as we're kind of looking through the overall budget of one care we know that these funds also must be included in terms of trying to come up with an overall per member per month investment is that a reasonable question I think I understand you're getting at it and trying to put something together that gets at Medicaid kind of non-partner funding of admin programs to help you understand kind of the additional money they're putting in above and beyond rate are they the only ones Medicaid is the only ones putting in additional money so what is supposed to this Medicaid funding I would not say most of this is Medicaid that's the question something that is funded under the withholds from hospitals something that is funded by the 7.5 million from Medicare for the blueprinted SASH payments trying it forward so it's kind of a mix so my question is as best as you can is just to tie this total amount out to the various sources of funding not just Medicaid but a couple of other examples any other questions I have a couple of comments on the social determinants of health and adverse childhood experiences life this is really just more of a comment I thought not all of you were able to come with us for our visit down there but I thought it was interesting to really see how some of these investments were playing out in a community and for me at least it gave more of a qualitative feel to some of these activities we had one of the participants at our meeting was talking about the Amplify grants and how they were looking at using those within the community to re-engage youth activities and promote more exercise locally and that kind of thing so I just wanted to connect those two dots out loud because I thought I would see how some of this is catalyzing a different kind of relationship in at least one community that we visited financial observations 44 and I can follow up with Kelly but I wonder whether the change in the admin expense ratio has anything to do with the way they're now handling the risk reserve which they're not including originally they had it as an expense for 2018 and then now in 19 they have it as net income it's left over that might be what's driving the change from 18 budget down to projected and then so we really should look at that because if we're including that in the numbers it should be in the admin expense ratio that's not the way they're categorized I think but I think it's a difference because if you remember in their budget of 18 they had a million five in there and they didn't spend it they only spent about 700,000 so that's in their 18 and then they're putting 2.2 million in a reserve of 18 and it used to be added back in 2.8 and 19 so I can jump with Kelly on that but Any other questions or comments from the board? Questions or comments from the public? Is that with indirect investments that one I noticed that you have implementation of the next gen medication waivers can you explain how implementing a three day stay waiver is an indirect investment in community provider? Several of these Medicare waivers were interest with the community providers because it provided for them to care for their patients if the patient is so elected to waive their three day stay and go directly to the home Understanding the three day waiver as part of the three day stay implementation committee that met with one care when I worked for the department of disabilities aging and independent living and all that the three day stay waiver does is it skips the part of requiring someone to be in a hospital for three days before nursing home would cover them for care in a nursing home for Medicare would cover them for care in a nursing home they don't get any other enhanced benefits they get the same home health that they would be entitled to otherwise so I'm just not understanding where an investment is being made in a community provider So as we mentioned the investments are not always financial they're value based and so we see potentially the next generation program is offering value based alternatives to the traditional Medicare program I would love a concrete example of how any community provider is benefiting from new implementation there's something that they receiving something in value that they wouldn't otherwise receiving from their women that we could follow up with one car on that Any other public comment or questions? Yes So Mike Fisher healthcare advocate so we did provide a written comment to the board I think late last week and I'm not going to review that now but I did want to speak on a high level that I know over the last couple years many from a compared perspective or from other policy perspectives have approached one care with a great deal of giving them the benefit of the doubt because after all they are building something that hasn't been done here before and there's a lot of details that we really do need to figure out how to do I appreciate that and understand that dynamic I also believe that we have now stood up one care one care is functioning and I guess my general comment to the board is that I think it's time to ramp up our level of scrutiny and our level of accountability so that's my general comment as we go forward and as we go forward we will continue to attempt to ramp up our level of scrutiny thank you Mike Susan just another question about some of these investments some of these investments are directly covered by DEVA's investments contracts with one care with delivery system reform investments and I'm just wondering if it asks one care in its budget documents to indicate what percent of dollars is one care just passing through as with the SASH and community health payments and the stuff from DEVA and what monies are coming from one care is the income separate from public dollars just to know what the public we're calling them one care investments but they're really public investments with Medicaid delivery system reform dollars directly from Medicaid to one care via contract but they then become one care investments and I'm just wondering if there's any way that we can trace what the public investment is for these community provider investments I mean so one care is an income statement has kind of program revenue that it's expecting or budgeting broken out in a great detail fashion that's in appendix 4 of the submission online if you want to look at it and see if that is sufficient for you or if there's additional kind of detail that you're being that'd be helpful I see the money coming in it's just a question of the money going out you know so it would be nice to know if all of the money from Medicaid is laying to these community providers I just don't know if there's any way to track that okay we can try to work on something okay other questions or comments from the public closing words of wisdom Mike just a few time steps we are doing our level best to get the data we need from Medicare we're still waiting on data from Medicaid for the Medicaid rate case we're trying to you know make sure that Jackie Lee is talking with Waigley to get all set up so that that goes as expeditiously as possible and we are targeting the number 28 as we will come back to you with recommendations on the rate and risk and all the stuff that I know folks are probably antsy to talk about but it may be the 12th though to be honest it may have to be the 12th but we'll we'll keep you informed about how that's looking and like I said earlier December 17th that one day is kind of the day we need to happen in terms of going from the Medicare date to the extended public comment period given our timeline extensions to December 10th with the expectation that December 12th will be the earliest day we will so you don't believe that October 20th is possible we're supposed to hear back on the timeline for getting some data so we'll know whether that's realistic or not later just concerned that if you extend the public comment that's pretty much saying it's going to be December 12th well December 12th I would assume that it will grow anyway we can be on November 28th can I just add to that November 28th meeting we had the ACO information scheduled in the morning not in the afternoon we had a pretty busy day that day so just exactly 20 years okay thank you Gene thanks for all the hard work cool is that a real date? the website still says the number the website so it is a real date is there any old business to come before the board seeing none is there any new business to come before the board just an adjunct can't raise your hand there I'm kitchen to say no seeing none there's an emotion to adjourn moving seconded to adjourn I will signify by saying aye aye thank you everyone have a great day


One of the oldest, most widely recognized gods through ancient Mesoamerica is a being known as Tlaloc. Worshiped as a giver of life and sustenance, he was also feared for his ability to send hail, thunder, and lightning, and for being the lord of the element water. Appearing in many forms throughout Aztec history, as usually water-dwelling creatures such as amphibians. Would his roots actually date back to the so-called great deluge, which has been noted in so many ancient religions throughout the world? Undoubtedly the most impressive depiction of Tlaloc, which can be found anywhere, is his megalithic statue, found in the small town of Coatlechan. Clearly once a pilgrimage site, what's impressive regarding the statue is its size, weighing in at an estimated 168 tons, the largest existing monolith in the Americas. Made from basalt, the workable stone for this monumental artwork was, at some point, transported to this spot in preparation for carving. The question is, how did our ancient ancestors move such enormous lumps of basalt, similar in size to those of the Moe statues, synonymous with Easter Island? Why did this ancient people revere water gods so much? Were these gods inspired by traumatic memories and legends, left to them by their ancestors? Possibly a surviving fragment of the once flourishing civilization, responsible for so many now unexplainable sites all over the world. Intriguingly, according to Aztec belief, Tlaloc was a god primarily connected with meteorological phenomena that was related to water. In 1963, the National Museum of Anthropology in Mexico City decided that the monolith should be placed at the entrance of the museum. The people of Coatlechan eventually agreed to this request on the condition that a government road, a school, and a medical center be built in their city. On the 16th of April 1964, the monolith began its journey to Mexico City. The monolith of Tlaloc was transported on the back of a giant, purpose-built trailer over a distance of about 30 miles. When the monolith arrived in the capital, it was greeted by a crowd of 25,000 people. Upon its arrival, the location mysteriously experienced an unusual storm. Clearly, an incredible ancient artifact, which we find highly compelling. The modern-day institution, man's way of organizing belief systems into their different clans, cult-like attitudes, often driven by an existential perception, specialisms of some form or merely a naturally occurring passion. They are either built around a certain series of events or an apparent fact or claim, which stand as the cornerstones of said institution. It is therefore within the profiteers of said ideology's interests to not only suppress any evidence that may surface that would make their treasured institutions crumble to their very core foundation, but to actively destroy said relics whenever one gets an opportunity to do so. The Bamiyan Buddha, for example, apparently this monstrous carving perfectly bored into a sheer rock face in the Bamiyan valley of Central Afghanistan, is not only a relic, which we hypothesize, was left by a now lost civilization, but due to the facial features once masterfully depicted upon the statue, removed at some later time within history, carved flat, not only making its identification as Buddha questionable, it was for some reason completely destroyed during the Iraq War. This destruction, I propose, supports our prior posit of it indeed being that of a lost civilization's work, this being the sole motive for such actions. Interestingly, hidden voids found behind the carving, if it were indeed a solid carving, as one would have once presumed when gazing upon it, how were these hollow chambers once placed behind said carving? Additionally, not only do most modern institutions deny any of the evidence we so often put forward on our channel, often in regards to a past lost civilization, but fields such as geology is simply actively writing off countless ancient sites and anomalies as simply geological coincidences. Their existence being an impossibility according to already established supposedly concluded chronology for human civilization. One reoccurring strategy, which I like to call the Paridolia effect denial, as befallen countless sites of interest. One of the most hotly debated, being the face on Mars, now simply dismissed as a trick of light, the intriguing pyramidal features nearby, which also somehow align with Pleiades. This denial strategy has condemned other said features here on Earth, some of which found in remote places that, according to modern academia, have simply never been inhabited. Thus, regardless of the artificial nature of such places as Gornia Shoria, must be dismissed as mere coincidental geological features. The ruins clearly amends age, often used in an unfortunate twist of fate, as support of such claims, as nature eventually reclaims all, thus the older the ruin, the easier this said denial strategy is to argue. That is, until now, in a modern era, where modern technology now allows us to collect a massive amount of information on simply anything, unexplained features, booparts, and many other advanced unexplained legacies of antiquity, once hidden, now shared far and wide, evidence which flies in the face of modern paradise. The Sharanian is yet another of these curious, clearly immensely old anomalies, that regardless of its form, once being carved from extremely tough rock, maybe this is why our lost ancestors built with such enormous stones, and did so in an as yet unexplained, yet clearly highly advanced way, known as polygonal masonry. Perhaps they built like this so that their footprint here on our planet be long lived, and to deliberately be resistant to the elements, to reach us now in the modern day, giving all of us an opportunity to understand the real history of our Earth, regardless of what others would like. We find all of these things highly compelling. There are countless yet to be explained ruins which can be found all over our globe, the proof of a now lost yet once highly capable possible pre-flood civilization, having once existed and subsequently vanished, suddenly and inexplicably, has now been identified on reportedly every continent. It is a continual problem for an academic world stuck on a paradigm of primitive and incapable ancestors of modern man, to explain these ancient anomalies, especially the many megalithic structures built using blocks, sometimes weighing upwards of a thousand tons in weight, cut, quarried, and then carried and lifted into place, all seemingly with ease. The only megaliths that any funded mainstream institution has ever attempted to explain are either those which are difficult to avoid, such as the ludicrous fictitious illustrations made as an attempt to visually explain the construction of the pyramids, or those that lay unliberated or seemingly abandoned suddenly. For example, the Stone of the Pregnant Woman in Balback, long contested as abandoned due to the gradient of the geography, particularly due to its weight of an estimated 1,000 tons, which has since, however, been recognized as not abandoned, but part of an enormous prehistoric structure which, thanks to the partial excavations which revealed this, covered an even larger block below it. This denial until excavation was a mainstream explanation for its existence. All the while, this conveniently ignoring the trilithon, also found within Balback, set aloft meters away, three 1,000-plus ton blocks sit within part of yet another ancient structure. Another megalith, which requires explanation, is a statue, once claimed as Apollo himself, yet clearly cut with a technique reminiscent of the Moai, found on the incredibly remote Easter Island, which also possesses the lost technique of polygonal masonry, yet I digress. His proximity to the Greek town of Apollonis, being the reason for this claim of identity, although others have claimed that his actual identity is in fact Colossus of Dionysus, thanks to Wilhelm von Massau, who identified him as so in 1932. Today, it is simply classified as a kuros, a freestanding stone Greek statue, regardless of the fact that it is not freestanding, is carved from solid-grade Naxian marble and weighs around 100 tons. Predictably, when such figures in terms such as 10-meter-tall, solid marble, 100-ton standing statue enter the discussion, cognitive dissonance has seemingly overtaken the poor fellow who was responsible for its attempted explanation for transport on Wikipedia, specifically during the well-studied, well-understood ancient Grecian area, stating, quote, any explanation for how they intended to move the statue was not carved into stone, end quote. Short-circuiting during their contemplation of the gargantuan task, they had placed upon this well-known civilization. Thus, the questions remain. Who was the kuros of Apollonis? Who was cutting him free from the marble? And what happened to this civilization so suddenly? We find such questions highly compelling.


All right, this is one of the most important teachings that I've given to my clients, to my students. It's called the Three Stages of Content Creation. So this is for any of you who want to get your message out there by writing or by making videos or by recording podcasts, maybe writing books, maybe creating online courses. So the Three Stages came about because I was noticing a common mistake that a lot of you are making who are wanting to create content, who want to write or make videos, et cetera. And the mistake is that you get so excited about some idea. All of us have had that experience where we have a peak experience, a mountaintop type of experience, transformational, life-changing type experience. Or sometimes it's just an idea came to you and I'm like, oh, that's such a cool insight that I look forward to sharing with other people. So you've got this great idea or this passion and then you work so hard at writing a book or creating a course or you just spend a long time on writing an article or making a really great video. And whatever it is you spend all that time and energy and sometimes money creating, you put it out there and what usually happens, silence. You don't usually get the kind of response that you expected. Right? Have you had this experience? I would love to know. I certainly have had this experience many times. I have thought, wow, this is such a brilliant concept. This is such an amazing idea that changed my life or whatever and I share it and then my audience doesn't get it. There's far less engagement in that video or on that writing than I expected. So the reason we have that experience is because we are human beings and we can't read the minds of our audience. Now, maybe some of you can but I certainly can't read your mind. What happens though is I can get to know you over time and get a sense of what will really help you or what will really inspire you but it takes time to get there. It doesn't usually happen because you had a brilliant idea one day and you share it and instantly your audience loves it too. Now that could happen too. If that's happened to you where you share some brilliant thing and your audience loves it, you're very lucky. It doesn't happen often. So we are often stuck inside our own head thinking about some great idea. We share it and then the audience, we kind of miss the audience goes over their head. So what is the solution to this very common human bias of being inside our own head and having disappointing experiences of sharing things and not having people get it? What's the solution? So this is how I came up with this idea of the three stages of content creation. So stage one is what I call casual content. So this is where I encourage you in stage one to create as much as you can to create and share as often as you can on social media or wherever you share your content. Stage one means that some idea that is coming out of your mind and your heart is touching your audience for the first time. It's actually not about how hard or long you worked on an idea. You could work on an idea for five years or for five minutes but the first time it touches the audience it's still considered stage one because we don't yet have any responses from our audience. So that's what I mean by stage one. It's the first time an idea touches the world, okay? An idea from your head, from your heart doesn't mean that it's the most unique idea in the history of mankind. Other people could have said the idea but it's the first time you are saying the idea whether it's in a written form or a video or a podcast or a book or a course the first time the idea touches your audience is stage one content by definition. So what does that mean? That means that it's a better thing to spend less time and effort on stage one content meaning you should always test ideas first as quickly as you can with the audience to see if it resonates with them before you take it to stage two. So let's complete stage one. It is casual. I hope you make it casual because I hope you don't spend too much energy and effort creating it because you want to test it with the audience as soon as possible. So try to just don't spend too much hard work on this. Just put it out there as quick as you can. Let it be casual. Try to be prolific with it so you can have many experiences of testing things and be exploratory and let yourself explore what the idea is, what the experience you had was, okay? Stage one casual prolific exploratory. And then what is stage two? Stage two is to improve on what the audience has been responding to well. Okay, so stage two is when you look at the stage one pieces you've done and ask yourself which one of those stage one pieces of content got the best response from the audience? The ones that got the best response you then take it into stage two. Stage two is to improve on what's liked, that's stage two. So you take something that the audience has responded well to and then you edit it, you improve upon it. Maybe you make the examples more clear or you add another example or you take away some part of stage one, the stage one piece that wasn't as, you know, it could have been improved. So you edit that piece that already respond the audience responded well to and then you redistribute it. You make it be seen by even more people. So at stage two, you may decide to use some paid advertising dollars on a social media platform to get that piece of content to even more people because you know that it already has resonated with your audience and it's probably going to resonate with even more people. Now, for example, what you're watching here is a stage two piece. I'm improving on what has been liked before and you know what's gonna be even bigger improvement? To show you my cat here on my left is my cat and you can look at her the whole time. It's much more interesting to look at than me, right? So cat videos. All right, so stage two is to improve on what's liked taking what's working from stage one and make it even better and distributing it even farther. What is stage three then? Stage three is called integrate and productize. What do I mean? You then take what you created in stage two and then you organize the stage two content into various themes and then you productize a particular theme. What I mean by this is if you have written some articles in stage two, they worked well in stage one. You've edited, made it even better in stage two. Now you organize those articles into various themes and if a particular theme would do well as a book you think, okay, this could work as a book. Even if it's random inspirational essays on a topic it can work, okay? You put it into a book as a result because you know that those ideas I've already worked with an audience, people already get it. And so when you put it into a book people will read the book and go, oh yeah, that makes sense. Okay, or if you've made videos you could take the stage two videos and organize it into an online course. You may want to add a few more things to fill in the gap, whether it's a book or a course but stage three is about integrating things from stage two and making it into a product. And that is exactly what I have been doing for years now. I've been doing a lot of stage one pieces and then taking some of those things, putting the stage two and then taking some of those things and then writing books. I have four self-published books now which are a bunch of stage two pieces of content.  So those are the three stages of content creation. I hope that you may need to watch this video again or read the article that's associated with this video to really rock this idea of, okay, am I taking things too quickly into stage two before I've tested enough with stage one? Does that make sense? A lot of people don't even know that stage one is stage two exists. So that's why they work so hard on writing a book or creating a course and then having it fall flat. And I just, it pains me whenever I see that. So that's why I urge you to do the three stages of content and I am a guinea pig. I'm a model. I've been doing this now for years and it works really, really well. In fact, like I said, this very video that you're watching came out of a stage one piece of content from 2017. I just shared some quick ideas when I was on a dog walk and the audience really liked it. So I ended up writing a more detailed article about it. That was my stage two article. And then finally I took that and put it into stage three. It was a chapter in my book on authentic content marketing. And so now I'm re-recording the video. This is really a further improved stage two video because this is not a product, but this is a free video. And hopefully this will make sense now to a lot of you. And I've now practiced essentially having done this idea several times over the years. Now it's become much more refined and my cat agrees with that. So with that, I wanna thank you so much for watching this. My name is George Cow, authentic business coach. I love talking about how to build a business and build a true audience with your authenticity with being real with your audience and finding your authentic and best voice to express in building your business. So if you enjoyed this, I think you'll like my other videos and thank you again for watching. I look forward to your comments and your questions below. Take care.


If you don't have a binary file in that executable folder, then you need to specifically tell IAR to generate this binary file. You can do that by right clicking on the project area there and selecting the options. And we now need to go to the output converter and we have to say tick the box for generate additional output and then select the binary format as the output file that you want to generate. So once you have selected that, you OK the screen and then you have to rebuild the project again. So you have to regenerate using F7 and then that should add the binary file to that executable folder.