Okay, we're going to get started. Welcome to the Green Mountain Care Board meeting. The first item is the Executive Director's Report, which I understand is very, very brief. Yes, I will just say that our June calendar is posted on our wedding busy month plan. I do want to put in a plug that tomorrow or before that also is open to the public. Okay, great. Thank you. The next item are the minutes of Wednesday, 8.9, so let's go move. Okay. That's been moved to approve the minutes of Wednesday, 8.9, loving the additions, solutions, or corrections. Is there any discussion? Seeing none, I'll ask Mike Barber to call the roll. Any comments? Yes. Chair? Yes. Can we go on? Yes. Can we go on? Yes. Can we respond? Yes. With that, we'll invite the team from one here to come forward. Okay. So on behalf of the One Care Prompt Management Team, we are happy to be here to provide an update on our 2019 activities. I'm Kevin Stone, the Interim CEO. Our budget submission last fall reflected a work plan that by necessity contained a number of uncertainties. And today we will provide you with more specifics about how the year is playing out. I'll give a high level summary of our 2019 performance so far, and then Tom Boris and Sarah Barry will describe in more detail our accomplishments and challenges. If I could characterize our work this year, and certainly my work as Interim CEO into one theme, it would be relationship building. And we spent a lot of time trying to work on either initiating and developing new relations or furthering those that were already underway. We're all concerned with continuing to grow our attributed lives to achieve the skilled targets set forth in the all-care model. Our ultimate success will depend on strong collaboration among several partners. We've enjoyed an excellent relationship with Diva, and this year One Care made strong gains in the Medicaid allies. We now have 70% of the attribution eligible Medicaid lives in One Care. And we have an opportunity to go further based on our learnings from a St. John's Group pilot, which Sarah will speak to more in her presentation. Medicare continues to be challenging for us, and you've heard testimony at the Rural Hospital Challenges Forum that you posted earlier this year. We continue to work with multiple stakeholders to try and find avenues for more Medicare participation that is aligned with provider need for sustainable operations. While we are not showing much growth in the self-funded ERISA plans and large group this year, much work has been done to find common ground and set the stage for significant increases in 2020. We have had productive discussions with all of the Vermont commercial payers, and we anticipate one new contract coming on board in October. Most importantly, however, we launched a process three months ago to work with Vermont's largest payer, Lucrosple Shield of Vermont, to establish a broad relationship that could include all of their products. I'm pleased to report that these discussions have gone very well, and we are close to forging a new relationship that could add considerable alternative lives for next year. In addition to the payers, this year we've continued to build relationships with our participating communities as we move forward in this all-payer model journey. We continue to provide support to primary care, the backbone of our model, and we are also moving to broaden our impact on all contributors of health. An important area of focus is prevention and social determinants. Over the past year, we have expanded RISE Vermont into eight new communities, comprised of 31 towns. We initiated programs aimed at adverse childhood experiences and developmental understanding and legal collaboration for them. Everyone known as Dulce in the acronym. This focuses on the first six months of childhood. We've also had initial discussions with Let's Kids Grow and we're beginning to explore possible areas of future collaboration. We have held discussions with the leadership of Delta Dental, recognizing that oral health is a contributor to overall health, and can be a cause of avoidable ER emissions. We agreed to begin to explore areas of possible innovations that could impact overall quality and cost. In addition to our ongoing support of mental health, we launched a process to explore more specific programs where one care and the designated agencies can partner, both in the near term and in the longer term. And we're anticipating initiating at least one new project before the end of this calendar year. One exciting program that we initiated this year was our Innovation Fund. This provided seed funding for communities to launch programs that would impact targeted concerns within their specific geographic areas, but that would be scalable to other communities and sustainable over time. We had such an overwhelming response to our initial request for proposals from the communities that our board voted to redirect some money's originally planned for other areas to increase innovation funding so that we can support more of these community projects. Since I am now in my last couple of months as interim CEO, after you get the details about 2019, from Tom and Sarah, I will conclude our presentation by providing some of my thoughts on the lessons we were learning, the current challenges that we face, and implications for the long term future of the all care. Thank you. Thank you. So my name is Tom Morrison, Director of Finance for one care in SSBT today. My section of the presentation will really be a review of the budget that was submitted last fall and approved in the winter, and then an update in regard to the actual numbers that materialize for attribution, benchmarks, precipitation, et cetera. Up on the screen here, you'll see the table of contents along the border, reading the items, but this really intended to be a front to back update and review of the different components affecting our one care financial model. We'll start with an overview of our core programs and the staff. So as you recall, we're moving into year two or three of many of these programs, but it's always a start and reset for them. And starting with Medicaid, generally a smooth transition to the third year, believe it or not, on the third year of that program, which is great. As we continue along that journey, one of the areas that we're looking to improve is really around data in regard to the confidential claims and opt-out data sets. We've spoken about this before, that there are certain blind spots we at ACO have and working with our partner, Diva, to make sure that we have compliant data that allows us to do the best reporting we can to our HSAs and in aggregate and totals. One area that we're working on. Blue Cross Blue Shield of Vermont QHP program entering the second year, continuing to work very collaboratively with Blue Cross Blue Shield of Vermont and align the program models with the other core programs. One of the aspects of the role of this year's work is the delay in the data that has come to one care, which just is a little bit of a challenge for our network to get up to speed with the data that they need to go do population health management. Medicare, as Kevin mentioned, a concern in some areas, particularly regarding the benchmark setting process and methodology, it took some work to get to this point with a revised benchmark, which I'll speak to in subsequent slides. Continued claims and processing errors under the Alma-Busin population based payment for the most part of those seen to have been resolved, but it does represent work for the revenue cycle teams of the precipitated hospitals and also a distraction both at the one care level and the network level, we need to fix these problems. And then also, as Kevin mentioned, the magnitude of risk remains a talking point that our network doesn't let us forget and even those who have been in the program would have a year to get their feet wet. It's still the topic that is brought up often. Last in the slide, UVMMC self-funded program, happy to report that an agreement is in place. This would be retroactive to January 1st or just at the point now to start rolling that out, moving backwards. All right, next we're going to talk about attribution. As you recall, at the time that we're building the actual budget submission to this board, many estimates around what we think the attribution numbers will be. In some cases, some new programs that are in development that aren't a certainty at that point in time that we include this for the scope and evaluation of our intent in total. What you'll see in the chart at the top is the core program broken down. Our budget model had 153,000 core program lives expected. We ended up with 160. There were some ups and downs and then we had a really strong attribution in Medicare and Medicaid. And then the Blue Cross QHP was a little bit under the model number, one reason being that CUNY Health Centers are burning that program, hope to address that in the future. And then the self-funded model, really taking a different strategy. And we learned a lot from the 2018 UBMMC pilot year. And we're looking to work with our partners at Blue Cross Blue Shield and Vermont to develop a broader reach strategy that brings in more self-funded lives through a single contract point for us. And we think that this is a better path to helping achieve skilled target goals. I'll also mention that there is one commercial self-funded payer that we are still working with and engaged with. A lot of details still to work out, but we are targeting in October 1st a live date that could result in lives that qualify for the skilled targets in 2019's business and then we'll continue in 2020. Thanks Mark. So these are the PMPM targets by which our year end performance is measured. And I've indicated in here the 2018 actual PMPM, the 2019 Green Mountain Care Board budget PMPM, this is what we submitted as an estimate at the time. And then what our actual 2019 PMPM ended up being after any program negotiations or similar events. You'll note that for Medicare, there's both an initial number and a revised number. There was, as you know, an agreement to relook at the benchmark once we got into the 2019 program year that has occurred. We have a revised estimate at this point, but I think it's a good one to look at. What you'll see is a pretty sharp decline for that Medicare program going down 4.8% and 3.4% respectively for the initial and revised. For Medicaid, it came in a little bit below the estimated number. And for the Blue Cross Blue Shield Vermont QHP program that come in under, I'll mention that that program has a risk adjustment component that happens after the year, so that could be some of the difference. We'll know more about that. Certainly after the year's over, but we're also working with Blue Cross to get some mid-year telltale secure indication of whether this would be an upward adjustment or downward adjustment in the material. Self-funded, as I mentioned, we just got the contract signed in place so we're still in the benchmark setting process. And I can update you all in coordinate with that materializes. A couple of points I'd like to make about this slide is I think there's some opportunities for sustainability. One is the Medicare methodology and really just the point I want to make here is that there's some numbers that are, in my opinion, pretty far apart. Jumping from $870 PNPM down to 835 and up to 847. Those for our network and for me, as the finance director, represents a concern in terms of the sustainability and financial predictability of this program. Just for scope, the 2018 to 2019 built on the 55,000 lives roughly is a $23 million swing. Then the initial to revise is another $9 million swing across the whole health system, percentage-wise, not humongous, but there's still material dollars that we need to protect for our health system. For Medicaid, my note here is that we need to start moving off of a fever service base. We've seen some really encouraging results in that program, especially since we've been in it for a long period of time, and how can we move to a benchmark methodology that really looks at a population health view, starting to look at risk adjustment as a basis for how we set a benchmark that builds in some predictability and sustainability for the care delivery system. The last point I'd like to make is really all of these benchmarks have worked pretty independently thus far. We set our Medicaid benchmark independently from our QHP benchmark and independently from our Medicare benchmark. As we all mature in this paradigm, I'm looking for ways to find some alignment between the different benchmarks so that we can yield the results of the all-fare model it really hopes for, which is a sustainable growth rate over a five-year period. That's something I think that we can all work together to achieve over the next couple of years to find the formula or methodology that coordinates these different benchmarks and yields success. Total cost of care is putting out some big numbers here for us all to look at. In total, we jumped from $850 million of accountability up to $904 million. That's an increase of $54 million. This combines both the changes to attribution that we showed earlier and the benchmark source of multiple moving part of the view, but it does show that through the transition to the actual and the budget, we've moved up to $54 million in accountability. As a reminder, I'm gonna take every opportunity and I can't say this publicly, this is not new healthcare spending, this is just saying we, OneCare, are now taking accountability for the cost and quality of $904 million in spending, and that not all of these dollars flow through OneCare, some does flow through OneCare in the form of a fixed payment, but the remainder flows directly to the payer to provide it in a 3% discussion. From the total cost of care and aggregate begs question, what are the impacts to maximum risk? And we'll also send maximum reward. So 2018 actual, as it shook out with attribution attrition and things of that nature, we had about $20 million in max risk. We submitted the budget ahead, just shot at $35 million, and we're now up to $38.9. That's a significant number, so we're not hospitals bearing that risk, say that they're a little bit concerned. It's really in reference of this gross number, and they all have different portions of that. I'll note for the self funding program, we're anticipating an upside only, so there could be some potential upside in making this asymmetrical in total, but there is no downside to that program. So for Medicare risk, just to point that out, $27.5 million in substantial, it's spread over a smaller network of participants, so there's fewer to share in that risk, and I appreciate the hospitals when they said it's a concern for their boards in particular. They all have risk in fee-for-service, well, you can have years that are up, you can have years that are down. That is nothing new, but of the $27.5 million of risk, about $55 million of that is new risk. It's $15 million. That's risk related to services delivered outside of their facilities, but they are on the hook for them, so when an agency does care, or an independent primary care is not part of the hospital, all of that spending is now part of their risk, and for the CFOs evaluating the maximum risk exposure that they have, they're starting to look at what's the old risk that they had in a fee-for-service world, what's new to them, and looking at it through that lens. To protect against some of the downside exposures that now exist with this new risk in ACO programs, we have, or are in process of securing a number of risk mitigation strategies. The first is that the Medicare program calls for a financial guarantee that turned out to be $7.5 million this year. What we call last year is about $4.2 million. We secured that through escrow. We are employing a strategy to secure a letter of credit, which is a little bit more flexible for us, and allows us to scale over future years, and doesn't require locking up the cash, which adds a benefit. We have also secured Medicare risk protection with a third-party partner. Same as last year, the potential protection is up to $12 million, and that's really what we have, just a terrible year against our benchmark. We receive up to $12 million back as protection. And then the Greenland Care Board Budget Board reserves. This has began really to help us either add participation or sustain participation from some of our smaller hospitals. It's at $3.9 million, and we're on track to secure that. So one of the things I also want to mention about the risk protections is, there's a lock-in. It's about $23 million of risk protection. That's a good number. I feel good about that. For the hospitals participating, we can never promise them anything less than their maximum risk limit still, because the access to these financial guarantee protections are dependent on how the entire network shakes out. We have one hospital have a really bad year, but we don't activate our risk protection model. It doesn't qualify for our use of reserves unless it's in the fall scenario. And really, we don't want to use that Medicare financial guarantee unless we absolutely have to. So really, from the hospital perspective, it always comes back to that maximum risk limit number. But we do know that at the ACL level, we've just had a terrible year, there are some backstabs that can help us sustain and carry on to the next year. All right, so those are really the benchmarks and the accountability and risk components of the program. Next, I'd like to talk about really the one-care organization and the different cash flows that flow through it. And you'll recall maybe from some previous P&L views, there's some components, like the total cost of care benchmarks, for example, that really don't show up on our financial statements. The next few slides reflect actually cash that goes through one-care. So these are the real one-care values. This is how we fund our programs in the total. Overall, many of these numbers will change based on attribution if we receive a PMPM from the payer that helps us fund our operation if we have an attribution increase or decrease if we move a little bit accordingly. So general movement in that way is expected and not of any concern. A couple of numbers I'd like to point out as having more material change. The first is a very positive one and exciting one to talk about that we have been working very closely with Blue Cross Blue Shield Vermont around a program for the administrative services only lives and large group lives. This is what I view as really a long-range year so that in 2020 we can work with Blue Cross to get as many of these lives as possible into scaled, qualifying and target program. But right now we're partnering with them to really put some financial resources to engage that population in primary care so we're looking at lives that may attribute but not have an active relationship with a primary care doc and incentivizing that relationship and also looking at disease management and assessing the Gaussian care that makes this. So that's a really exciting positive that pushed forward. Next, you'll see a decrease in the self-funded space. This reflects two things. One is a remote and rural. It's a scale back. We anticipated adding more self-funded employers that one care would contract with directly. We learned a lot as I mentioned before from the UMMC experience and we decided to maintain the UMMC not scaled beyond that in the hope of a better strategy for 2020. So there's a decrease there that just reflects the loss of attribution. Next, we see the OUD investment revenue that stands for Opiate Use Disorder. There was a program that we were pursuing to do some population health management around those with an Opiate Use Disorder circumstance. Ultimately, that program was unable to move forward. Due to data restrictions under 42 CFR, while this is a body of work that we'd love to be engaged in and we have a group of patients that have no access to their data, it was a difficult program to move forward. So, potential of the future for a similar model but under the current data restrictions, it's just a group of work. Last, I'd like to turn it back a little bit to see if I can say something. Yeah, SAMHSA federal data sharing rule protects those who have a substance use disorder diagnosis and protects information. We certainly appreciate the spirit of it but in terms of doing ACL work, it is a bearing. Lastly, I'll mention the hospital dues. There was a small increase there. Those flowed really as the last number that I put into the budget and a lot of it will depend on where we see attribution increase or decrease. Medicaid generally pays the VHF costs for any lives that are treated there. So if you see an increase, it doesn't affect hospital dues. Blue Cross contributes to those costs. Medicare really does not and we saw an increase in Medicare attribution. It comes with no new funding from the federal governments of the hospital dues company. All right, so that was the revenue side of our one-care budget. Next, I'll talk about just with two buckets of cost. The first is the population health management investments. Most of these in a similar fashion to the revenue is based on attribution. So as our attribution changes, the expected cost changes accordingly. Some, the value-based incentive fund in particular is based on over-costal care. So that one can move a little bit too. But overall, not a lot of change that we experienced. Some ups and downs with the programs but overall came together quite nicely. We do have two changes of note here. One is that we had $2 million budget for a specialist program. For a couple of reasons, we are reallocating $1 million out of that fund in the two different areas. One is a mental health program pilot that Kevin mentioned. That's really working with the designated agencies to find the right partnership there for mutual benefit. The other is the innovation fund. We receive really strong, positive feedback from that process and have a lot of great ideas. So we wanted to put some more financial resources behind that program. Next, you'll see the expense side of the Blue Cross Blue Shield of Vermont primary PNChem program. So this is in balance. We're giving money from Blue Cross and hang that out to our network in balance in the budget model. All right, we'll care a lot of operations costs. You'll note that we had a $15.9 million budget approved by the folks last winter. We're coming out at 16.1. The general operations is actually down to $93,000. That's really a timing related adjustment based on hiring of new staff. We have this overall ramp up of operations total. The area that actually drove the overrun was the risk of protection model. That is built on the benchmark as a basis point cost model because we added, had more lives entered into that program than we expected. Our benchmark went up and therefore it was the protection cost went up. In evaluating the budget overrun, I believe it's still a good value to purchase and I think it makes sense to go forward with that overrun and it was approved by the board. The next grid, or something that we've been thinking about a lot internally, is that we have a lot of different functional areas that get bucketed on from just general one care of Vermont operations or admin. And there are a lot of different functional areas that receive a significant proportion of administrative operations funding. So we put in the chart here both in numerical fashion and in visual fashion. This is show the different distribution of the different functional areas. So we have clinical quality analytics and primary prevention, which is really a rise from line pocket. Patient support, which is the required call center access that we need to maintain for our attributed lives. Regulatory and government, which would include any work that would do if you're not a care board and the legislature. The risk protection, calling that out here as a separate line, and then really the remainder falls into general admin functions, which would be pretty typical in all these nations executive companies and so on. Next, we put our total one care of Vermont budget into a visual layout that includes both the population health management spending and the operations costs. You'll see that the pop out management represents 70% of our budget. And the total amount here is 54 million. So the 54 million is the top health velocity operations costs 70%, about 38 million is that population health management and bucket and the remainder are all the different functional areas that help support our work and support our communities engaged and by those care.  So we just showed or spoke to a $54 million cost for the one care programs, many of which are paid out to our network. This is the way in which that work is funded in the visual pie chart form. You see that there are four buckets here. The hospital dues representing to shy 39 hospital shared savings, eight million delivery system to foreign funding, 10.8 and pay your support to shy $8 million. Really, they're gonna boil it down to two thirds hospital resources and one third payers important government. So it's a significant investment that these hospitals are making in one care programs. And really, we wouldn't be where we are without their financial commitment. And that is what I had for the budget and finance update. I deferred to the board whether you'd like to do questions for me now or I can present to Sarah or we just keep moving forward. I think we're going to ask some questions if you need to, Sarah. So now we'll go right to Sarah and we'll hold the questions. Good afternoon, my name's Sarah Barry. I'm the senior director of value based care. And it's my pleasure to talk to you about some of the planning and study programs that we have going on across our network. I had many to choose from. I hope that I picked the right highlights for you all. I thought that we would spend a little bit of time talking about what we've learned in our complex care program as well as what we're seeing this year and looking forward to the future. And then focus in on some of our work around social determinants of health, looking at our top university work, for example, as well as an emerging partnership with the agency of human services. And then focus on some of our special clinical projects as well as the innovation funds where I'm pleased to actually share publicly the initial projects that we have just funded. So beginning of the complex care coordination program, we really in 2018 were looking at how to scale this program from an initial to four communities in a many big population into 10 communities statewide. And I think it became a critical year of learning and growth and development as our network really thought about how to move an aligned care model forward. And what that meant was lots and lots of discussions, workflow development, conversations about accountabilities, roles and responsibilities among and within teams. And so what we see is that from a long care lens, we invested about five and a half million dollars in 2018 in our communities. So that being our primary care practices or designated agencies, our home health agencies and our area agencies on aging, in order to support the capacity building, the development and the institutionalization of this program. One of the things that I think was very different for us as we then moved into 2019 is that learning that capacity building comes with lots of challenges and more clarity you can provide the better. We actually designed a clinical attestation process that we put into place in the summer of 2018 as part of our contracting process for implementation in 2019. And what that did was really spell out the requirements, in particular for our primary care practices across the network, for what activities they would need to do and the measures that we would be looking for in order for them to continue to receive population health management investments as well as the complex care coordination funding. And I think that that communication and accountability through a contract lens became an important lever, an important entrance point for us to be able to come in and provide more support from them in a way. So keeping this to a pretty high level because I have spent hours telling you about everything we learned and what worked and what did not. But if we just take a snapshot, the results from 2018 indicate that we really were working hard as a network to engage our members, our patients in relationships with our primary care providers. And so we look at this certainly at the high and very high risk population level, but I think in a broader population health management program, it's really important to look at that entire population. And so what I think we hear are the statistics for Medicare and Medicaid, indicating how many individuals actually had a visit, one or more visits with their primary care provider during that 2018 measurement period. And I'm really pleased to say that we hit 90% for the Medicare population and 82% for the Medicaid population. We had over 5,000 individuals across the year. We touched by the care coordination program. And of those, at the end of the year, just over 1,000 had a shared care plan indicating they were definitely in progress in terms of active care management. As we move forward and I start talking to you a little bit more about 19 and 2020, you'll see we keep ramping up the complexity on those definitions and what we're looking for in terms of expectations for engagement and outcomes. The reason I give you only Medicaid signals here in terms of actual outcomes information is that we need to have enough period of time to actually have a cohort group of patients active in care management to see what might be changing. And so it was still a very small cohort because we were carrying forward a very modest number of individuals from 2017 that we then tracked across the 2018 performance year. And what we could see there is that we had some modest decreases in remember per month spending in the high and very high risk population. And I think more importantly, the signal was in the entire population when it looked at the emergency department utilization. And so we are tracking these as well as additional measures on a rigorous basis and sharing it not only with our clinical committees internally but also out publicly within our network, really using this data to try to spark change in a little friendly competition along the way that it hurts. So when we look to the current year, I actually have an updated statistic for you that the numbers are changing very rapidly. So as of this morning, we now have over 1100 patients active in care management. So that's a more technical definition for us. That means that not only do they have a strong established relationship with that lead care coordinator, the folks we call the quarterbacks of that care coordination team, but they also have that care plan developed and underway. And so that is now kind of the primary marker that we're looking at to measure the progress and the penetration of this program across our communities. That represents for us about 6.3% of the high and very high risk population when we look at Medicaid and Medicare combined. And I'm really pleased to announce that it's the new court health service area that is leading the charge right now for the Medicaid population with a 14% engagement rate here as we just turned into the month of June. One of the other things that's really important for our learning and development is to address some of the challenges that have been brought forward to the board in other settings around some of our communication strategies around the care coordination software and care navigator. And so this year we are in a pilot program with a Rutland health service area around an alternative that they proposed to us, whereby Rutland Regional Medical Center actually built out a care management module in their electronic health record and opened up access to that module to all of their community partners to have a rewrite permission and really be able to share information seamlessly. They in turn are required to share the data with us on a monthly basis to help us with tracking and understand what is happening. I'll say it's still pretty early days. We've been extraordinarily impressed by how dynamic that team is and being able to stand something up so quickly and to engage and really partner with their community members. We will see how all of this emerges and we are looking to see whether at least one other health service area might move forward with a pilot as well. Kevin spoke in the beginning of our remarks about Dulce, the developmental understanding and legal collaboration for everyone program. And that is now moving into an operational phase. In our budget proposal, we have indicated that we were interested in scaling that to three additional primary care practices. And as you may recall, this is really an interesting collaboration between a primary care practice, a parent child center and legal aid all supporting the needs in what we call a two generational approach. So looking at the family probabilistically but using the touch point of the birth of a new child and their first six months of life to identify where there might be either the potential for adverse childhood experiences other risk factors that may be able to be proactively addressed that surround not only that child and the parent or caregiver but also impact the rest of that family constellation. And so we've been really excited not only to get that off the ground but also through a partnership and collaboration with the maternal child health division at the Vermont Department of Health. They have been able to bring some funding forward and actually expand that to a fourth site. And so just at the end of last month we had a group of just over 20 Ramonters part of this program go down to DC and you can train in the model and they are now in the process of really scaling that into the communities over the course of the next few months. Next up I wanted to talk just a little bit about the St. John's very pilot. This is an exciting innovation that addresses really the intersection of our goals around cost containment, clinical care delivery and system transformation. And so you may recall that in this pilot we were looking at a different model or approach to attribution for the Medicaid population. We call it geographic attribution. Really what it's doing is looking at the zip code basis where somebody lives and defining that as the unit that allows them to be part of the ECO rather than a relationship associated with their primary care practice. And then once we identify that cohort we've been working very closely with the community in St. John's very to set up a pair model that is inclusive and aligned across all of the programs so that what we're doing is actually leveraging the local ECCI staff. So the Medicaid or FEMA staff on the ground to help with some of the initial screening and assessment of those individuals that don't have a relationship with their primary care provider and help to then align them with the care model that we're bringing forward. So to use a screening tool and based on the responses to that either via in-person or maybe a telephone they've interviewed to say this individual looks like they might be high risk or very high risk. How can we then engage them and help form that primary care relationship? One of the interesting lessons learned early in this process has been to try to map and understand the complex relationships that already exist. So just because there's not a primary care relationship doesn't mean that care is not occurring in that community. It could be solely through the emergency department. It could be through a designated agency or other community provider. And so everybody has just a slice of the pie and what we're trying to do is figure out how we can share all of that information seamlessly and really coordinate that so that whether you're healthy well in 23 and getting your second or third job thinking about a family or whether you are later in life and perhaps meeting some additional screenings and supports, we have you back. We have you covered. At a third angle to this pilot that we're excited about and really looking to the leadership locally in the St. John's very health service area is around primary prevention. And they have as a community come forward and said that they would really like to identify some strategies to invest and build on the work of their local accountable community for health. And so on a voluntary basis they are looking at using some of the ACO-related funding that comes into their community and putting it into a separate fund that has been directed by their local stakeholders in terms of the investment strategy. And so they have a goal of having that process set up this summer and then we look forward to seeing what some of those initial decisions are that they make about where they want to invest some of those dollars. I think one of the challenges that I do want to mention related to this pilot is we consider whether this is something that we could scale across other communities moving forward is that from our perspective this is an opportunity to provide better and more coordinated care and that may come with a cost and that cost might not be easily knowable upfront because this might be a population that again is not traditionally accessing care and services so even if they're preventive based services those might even cost within the healthcare system and I think it's important that we all acknowledge that and really strategize around how we might best address that moving forward. So the final topic I wanted to touch on from the complex care perspective is really about our plans to evolve this model as we move forward. One of the things that we are seeing is that the investments that we made in 2017, 2018 and now in 2019 have really been in a framework of capacity building. How to be low funds into our partners and allow them the time and space to hire the workforce, train the workforce, reallocate roles, figure out how to better develop workflows and communicate within and across organizations and that has been a crucial component to building a solid foundation. But now from our board and from our clinical committees perspective it's time that we are really focused a little bit more on moving from that capacity building to making sure that we create the value and doing so by measuring things like that patient engagement and the actual patient outcomes. And so we were charged with really developing a process that was inclusive across our network over the last couple of months to evolve a payment model change that we will implement in 2020. And so I would just give you from high level what our process looked like and what some of the outcomes of that looked to be. So firstly this is a process that was directed by our board and really a minister that we're seeing by our population health strategy committee and our finance committee working closely and iteratively together. They asked us as a management team to set up a series of focus groups and so we held three rounds of focus groups, a total of five of them both in the Northern and Southern part of the state. We identified key stakeholders that really represented all different partnerships as well as perspectives on care coordination whether that be the on-the-ground person delivering that care coordination or a financial advisor, an administrator. And I was very impressed overall by the amount of active engagement in that process. We haven't actually planned for that focus group. They asked us for it and they actually asked to bring the Northern and Southern groups together. And so I have to say in all my years of focus groups that's the first time somebody's asked for something like that. So a very fun and engaging process. We, I'm very happy to announce, were able to get to consensus with so many different stakeholders and really put a model forward to recommend back to our committees that was looking at how to make as much progress as possible in a iterative fashion and also breaking out break the infrastructure that we are still building. And so the foundation really for us as we look to 2020 is approximately a $9 million investment. We are funding the same partners that are currently eligible today. We are completely eliminating the capacity-based payments, that pyramid that you've seen from in the past with the foundational money going into communities and organizations will go away. And in its place, we will create a series of significantly increased per member, per month payments.  Recognizing that multiple care team members means multiple payments. It's not that they have to split those payments.  We also recognize that just from an operational perspective that this new payment model would not go into effect until April. So the beginning of the second quarter of 2020 and the reason for that is that the timing of data flow to us and our ability to then risk stratify and copulate the information that our communities needs to really proactively outreach and care for this population just can't happen easily at the turn of a calendar year. And so from a care coordination lens, we're just kind of tweaking the calendar a little bit for them to really help support that smooth transition. The other thing that we will add to the payment model is a payment related to care conferences. Those are known as a best practice nationally when it comes to complex care management and something we have not funded before but really feel like that is another step forward in implementation of our model. Finally, we have identified two kind of cardouts from that total funding that we are still working with some work groups to better formulate. The first is a cardout for pediatrics and so I'll speak about some of the details in a moment but recognizing there are some unique things that we want to respond to at the request of our network to better serve that pediatric population. And then also we are looking to fund a pilot with our home health partners around a longitudinal care program that had initially been piloted in the Chinatown and Randolph County area showing some early success in both outcomes and cost savings. And so we are working to see how we could scale and test that in some other rural communities moving forward. Interestingly, I think the last talking point in terms of where that financial model is going is that at a minimum, putting that type of investment into the system is creating, we anticipate about 73 new FTB to support that complex care work. And my guess is it's probably a higher number than that. So the details coming forward related to the payment model are really around working out some of the technical details with our network and then having a very robust communication process. And so we will be out conducting town halls and every health service area in July to make sure that together all of our partners are hearing this information and able to plan proactively for this transition that is now roughly nine months away. Promise I won't be that much debt for every slide. So for social determinants of health, the two things that I think are really critical in terms of progress are that one care has been working closely with leadership, the agency of human services across multiple departments and divisions to really identify where there might be opportunities to break down what have been, I would say, legal and operational challenges to the alignment and sharing of data in support of care coordination for our joint members of patients. And so I'm really excited to see that there's some new interest in that. We have actually together just submitted an application for some external funding and technical assistance that might help further that at a faster rate. But regardless, we are committed to that partnership. It's too early to say which field might emerge whether it's corrections data or mental health data or something else in the realm of social determinants. But really the engagement is what we're most excited about as we then start to feel back those layers of complexity. And then second, we have continued our work with Algorax as we've spoken about before and are very close to finalizing our pediatric risk score, pulling together social determinants of health data to identify whether that can help us better refine some of our approaches to identifying individuals and families that might benefit from outreach and support. We also have begun working with them on a special project that we've called an ACES proxy score. So we're trying to look for are there other data sources that we can leverage their expertise to bring together and align to shed more light on the complexities of the way that health and human services are delivered and best organized. And then finally in the area of childhoods adversity, there are multiple avenues that one cares exploring. I welcome into you tremendous amount of detail to be shared that with you in a report recently, but I'll just talk about the next couple of months briefly in terms of some of the highlights there. So I mentioned already the Dulce pickoff in May and then over the course of these next couple of months, we're very focused on engaging with the designated agencies around a mental health partnership related to quality measures and that aligns to the funding adjustment that Tom spoke to a few minutes ago. We also in June are working with some of our network colleagues as well as both of the Department of Mental Health in a field around something called Neuroscience, which stands for neurobiology, epigenetics, ACES and resiliency. And there is an evidence-based curriculum that is looking to be adapted for Vermont, targeting both health and human services providers. And so we want to explore together what this could look like and what opportunities and avenues we might best realize together to disseminate some of this information which really does promote resiliency in families but also in the workforce, which we think is critically important as well. June through August will be focused on the pediatric workgroup and also working with a medical student to look at perhaps a different approach to risk stratification of the pediatric population, as well as some other proposals our network is considering around more systematic social determine of upstreaming. And so by fall, I think we'll have a more realistic assessment of what we can operationalize for 2020 versus what might take us a longer period of time depending on the complexity and data sources. And then finally, in October, we are planning interdisciplinary grand rounds related to a pediatric social determinant of health topic. Very quickly on the skilled or sent facility three-day waiver, I just wanted to put a plug in here that we are seeing some pretty big scale or ramp up in the first quarter of the year. We have a little bit of a reporting delay here. So we just were able to access that data. We now have 59 patients in the first quarter of 2019 that utilize this benefit. And that compares to 25 in the three prior quarters as we were just piloting and implementing that program. Antique total feedback is extraordinarily positive from both providers and from patients about the value of this program. Finally, in the area of special clinical projects, there's a tremendous amount going on. But to just give you a couple of highlights, we are, I talked a little bit about the mental health payment reform program, really trying to address some of the challenges that we see around the mental health and substance use disorder related quality measures. There are five that we're accountable for under our payer contracts and the all-payer model. Many of whom we have some blind spots in terms of the ability to see a frost systems and be able to share information. So for example, in a 30-day follow-up from the Emergency Room for Mental Health, you might access one part of the system to understand that emergency room visit, a second part of the system in primary care to see whether outreach occurred there, and maybe a third or a fourth lens looking at the designated agencies or an independent mental health provider. And it's often quite challenging to make that system alignment come together. And so we're really looking for some creative new ideas from the designated agencies at one partner in that to help us. We also were looking at mechanisms to improve primary care and specialty care communication and most importantly, access to care. And we recognize that there are some really interesting models that have been tried in different parts of the country. One, for example, is an e-console. So an electronic consultation model whereby a primary care provider can get more timely feedback and support in clinical decision-making as to the appropriateness of that referral. In systems that have implemented these types of programs, what they see is that access actually improves, that the right people are getting to see the specialist and they're able to see the specialist faster, and that when they actually look at the acuity of those visits, they go off, which is what you would expect to see. It also has some data to support primary care provider satisfaction that they're really happy that they're able to more fully support that patient in their clinic and with a set of strategies that support that. We are exploring some work in the pharmacy area and particularly around an embedded pharmacy model. As we know, pharmacy costs are quite high and are continuing to rise, and medications are getting more and more complicated with individuals on multiple medications at high risk for inappropriate utilization and often difficulty following their medication plan. There's also a large body of evidence that we've been gathering that supports both the clinical and the financial outcomes associated with the LED to a set of very rigorous evidence-based interventions. And so we are really looking for opportunities to partner in a joint venture between one care and some of our payers to look at how we can move such a program forward over the coming months. In the area of chronic kidney disease, I just want to be clear that we also are including the end-stage renal disease population, which is a carve-out population for our Medicare program at every high risk or very high cost in our communities internationally. And here what we're looking to do is really support a integrated complex care management program that looks at how to better target us through the interventions for individuals with different stages of chronic kidney disease and help make better choices about their healthcare options and how best to support them. And then in episodes of care variation and bubble payments, we have just completed building a application on our Workbench 1 platform that helps us to start to drill down on the 90-day post-acute episodes of care really coming from the Medicare bundles. And we are starting to, I would say, feel back the layers of that information, try to understand the variability that might exist and what some of the drivers are with the intention that moving forward, we are looking to design and pilot several bundle payment options in future years. With respect to the Innovation Fund, this has been one of the most exciting implementations I think in 2019 and Ken and I already spoke to because of the responsiveness from our network. I'd like to just call out the fact that we gave folks about six weeks notice over the holiday period and had 45 proposals come in from 11 different health service areas and every single one was high quality, interesting and had positive potential. So we're made for quite a challenging process to review and really pick the best among the best of all of those proposals. We did and continue to run that decision-making process through our Population Health Strategy Committee and a series of reviews that ensue. And so we are just today releasing a press release indicating those first funded projects. The first is in the Middle Area Health Service area. It's an ocular telehealth and primary care program. So that is looking at basically purchasing cameras in putting them in primary care offices so that at the time that you're having a visit if you have diabetes and there is a concern about your eyes, they can actually take a photograph and send that onto a specialist who can read that photograph and send that information back to the primary care provider. So we're hoping to accomplish multiple things. There's an innovative use of technology in the States. We think that more people will actually get this test that need the test because we're doing it right then and there. And then we will use the local care coordination teams to help support that in a circular fashion to make sure that it follow up as needed that we can help organize and arrange for that. The second is in the Burlington Health Service Area is an embedded model, which is really a partnership between the Vermont Children's Hospital and a current child center, the Lunt family room locally, whereby they are really focused on a high-dease, high-risk population of immigrants and refugees who are known to oftentimes access the emergency room more frequently than perhaps would be ideal and that one barrier among several is actually just the logistics of trying to get to a primary care office during normal business hours. And so instead, looking to break down some of the barriers and add more comfort as well as anticipatory guidance and education by bringing the providers to them at the parent child center where they are already receiving supports and services in that location. So we're really excited. Some of the feedback from our top health committee members around this is that if successful, this could really scale to other populations in other communities quite easily. And then the third is in the southern part of the state down in the Bennington Health Service Area and it's a youth psychiatric urgent care model that is focused on diverting youth and adolescents who otherwise are being transported from schools to the emergency room because of acute psychiatric needs and so instead creating a lower stress, safer environment for them to be able to receive the screening counseling assessments that they may need and begin to set up a care plan. And so this is really an important partnership between the local hospital and United Counseling Service. It was very interesting to me just as an anecdote to see that in the final quarter of 2018, they were able to count 249 youth that had come to the emergency room that they felt had the potential to be prevented to another setting. And so if you were to scale that across the year, there's a thousand interventions easily. We will be in the next week or so releasing the second round for that. All right, with that, I'm gonna turn it back a little bit. Thanks Sarah. So what I thought I would do is just talk a little bit about kind of observations and the lessons that we are learning. I'm not sure we've learned that, but we're learning as we've gone on this journey. So one of the big issues is that true payment reform really has to move away from youth service and migrate toward population-based payments. But what we found is that setting up sort of fixed prospective payments that are population-based is extremely challenging for the payers. And that's been pretty much true across all the payers. And when an attempt is made then to do that and there are operational problems that then result in confusion among the provider network, that increases provider anxiety and it dampens down then the interest among providers to participate in a quote, voluntary program. And so that's gotta be an area I think that we can try to improve by working together. If you think about moving forward into more population-based programs to have targets that are set over time that are fair, we really need more sophisticated risk adjustment. And you've heard Sarah talk about our pilot with algorithms to try to incorporate some of the social determinants into figuring out what is truly the underlying illness burden of patients so that you can truly set an appropriate budget that you would that whole community or group of providers that you can count on for. And I think a lot of exciting work is being done in this area but it's still relatively controlled. And so it's really not, I think, fully made. So then you couple that with the fact that we have a lot of small communities in Vermont and we don't have sophisticated risk adjustment methodologies yet. So we have to be pretty careful when we consider how much risk we wanna look to a smaller health service area or community to bear. And I think all of the all-care models stakeholders need to continue to keep working and how can we better support more broad, smaller agency participation in all of these risk models. And over time, I'm sure you think about this a lot. Your challenge on the regulatory side is how do you migrate from free-for-service-based budgets and rate management to population and total cost-to-care orientation? And all that has to be a lot. And of course, we all struggle with the dilemma underpinning all of this to do it right is we need timely, accurate and comprehensive data. And today that remains a challenge for us to get. So when I was a COO for 18 years, I used to tell all my director reports I don't want you to bring any problems to me unless you have a suggested solution. So I violated my own principle because I don't have answers. I just think these are important areas that everyone that's involved in trying to lead to the success of the all-care model needs to keep in mind and keep working on. So with that, I thought I would share a few specifics that I think we're gonna be focused on in the upcoming year at OneCare. So you heard Sarah talk about starting to think about segmentations within the population so we can be more targeted. Children have different needs than adults. We need to think about children in a more direct way and not just lump them in with all of the adults. You heard the learning that we have from the geographic pilot in St. John'sburg. What you didn't hear was that if we were able to attribute the Medicaid lives that were involved we would have added 30% more Medicaid attribution to the St. John'sburg community. So if we can take those lessons learned and apply that throughout all of our communities and potentially even more of our core programs that would be a great way to start to gain on our scale targets. And certainly conditions specific strategies will be a focus. We have started to look at bundle of paint, bundle of targets. Post-acute care management is an area that ACLs across the country have generally had success at making an impact and the really good ACLs have been able to reduce post-acute care costs by about 15 to 20%. So that's clearly needs to be an area that we need to look at. And we have all of the stakeholders at the table. So hopefully that's work that we can be successful at personally. We've made some strides in the area of woods but there's further to go and that will remain a focus. And disease cohort work I think will be important as we broaden our relationships with the commercial payers. So one of the issues when you want to get into true accountability is you'd like to have local communities where most of the care is rendered and where the members are known, the patients are known, you'd like them to be accountable. If they're going to do the hard work of making improvement and transforming the system, you'd like to reward them by being able to give them the benefits. But that bumps up against having a large in the population, a big enough end to have actuarial accuracy and costability over time. Holding someone accountable for a population that's small and has a lot of variation can actually be demoralizing because they feel like no matter what they do, they're buffeted by things that are beyond their control. So I think as we look forward and promote, we're gonna have to figure out what's the right way to balance local accountability that right now is at the HSA level, some of which aren't very big with the benefits of a statewide ACL that can create some pooling and try to offer some of the variation that actually occurs. So one of the things that we're gonna be exploring this year for a corporation into 2020 is, do we wanna start to introduce a blend of some of the risk-adjusted numbers by HSA with the historic cost? And to the extent that we think that makes sense, we'd like to explore that. And then that will have implications, of course, for how we then take our macro level payer benchmarks at the ACL level and bring them down to the community level. And again, we have to have accurate and timely claims to support application of any sort of risk-adjustment methodology into the HSA target setting. We've talked about involving the all-pair model policies and oversight to align and transition to the new payment and care delivery models. It's hard to do transformation. I think our providers remain really up to try to do that work, but they have to be allowed to do it in a sustainable fashion. And I think we've run into a little bit of collisions between what the trustees of some of our participating communities believe is prudent fiscal management with what would be looked to to make the full commitment to transformation. And again, as we think forward, as multiple stakeholders in the all-pair model, how we find the right balance to achieve the transformation throughout the state and recognize some of the peculiarities of smaller communities, I think will be challenging. And we're gonna continue to deploy new strategies to achieve greater scale. That's probably the biggest issue, I think at the one-pair level for 2020, is making a big jump for the scale targets that we're behind right now. I do think that we've done a lot of work to try to understand, within the ACL, but that also with the various payers, the differences between a self-funded account and the employers and public payers. And I think we've made a lot of good strides, and I believe we will see a lot of growth on the self-funded side. We'll just advance one more slide. So some of the things that we're doing, we have identified some of the attribution models kind of get in the way to attribute, we mentioned the Newport community, when I met with the Newport community, they said, we don't understand, we feel like we take care of another 2,000 patients that weren't attributed to us by Medicaid, we want to be responsible for those. Understanding what is it about these attribution models that seem to not attribute all of the lives that the very communities themselves believe they are going to be responsible for, we should work on, and maybe the geographic attribution is one approach to try to overcome that. I believe we will have a lot of gain on the self-funded, but we have to make sure we have a very clear value proposition to the employers. The employers opt it out of fully insured products, specifically because they want to take advantage of the commitments and the investments that they themselves are making and help the workforce. So we have to be supportive of that and added to that and not take away from that, and that's going to be the trick. I believe our partnership with Blue Cross, which will allow us to achieve that for the upcoming year. We know that there's some programs, some pairs that are in a core program that we don't have relationship with and we're meeting with them. And then lastly, provider participation. The more we have providers in the models, the more we're going to get attribution because the people that go to them for care will naturally attribute to the application of the models. We are trying to find ways where we can get some of the HSAs that are struggling and have been hesitant to commit to participate in any of the models to at least join us for one or two of the programs and I'm hopeful that for 2020 we'll have some opportunities to try to increase provider participation at least among those that aren't in now and also among the programs that some are only in maybe one program. So that's kind of what we're going to focus on for the second half of this year leading into 2020 and I thank you for your attention. I certainly welcome any questions that you and the board would have about the day. We'll start with the board. Are there questions for the board? And I guess I'll turn it to Maureen first if you have any questions, Maureen? Sure. Who's the person that you're talking to right now? Do you have an idea of what you're talking to and what you're thinking about? Do you think they're favorable? Do you know how that favorable is used to opt out of the things you're talking about? That's a good question. We are in the process of selling all of our programs. They happen at different times and not on the same schedule which we was a little bit to be desired to be honest, but it looks like overall it's going to be a relatively good year on the risk side. There's a little bit of a sour taste in everyone's mouth around the Medicare AIPVP reconciliation which is not the performance result but it's a big check that's being written back to Medicare. So I think it's going to be a good story overall. However, if I'm a hospital, I'm going to look at that as, I got some of my money back. I invested an awful lot in these programs and we're seeing some positive results and getting comfortable with the model but that money coming back to that doesn't necessarily mean that they have this financial windfall that they put towards reserves. I think it's something that can be considered on a hospital-by-hospital basis but overall I see this as, this is kind of the model. They pre-invest in these programs and put some money on the population initiatives in hope of getting the shared savings back that makes them whole again. So I think that's what we're going to experience at least to some degree. Thank you. Do we know when that will be fully recognized? I would expect that the Pupros-Blujiro-Vermont program and Medicaid program will happen and probably within two months time we'll be prepared to speak to that public what do we do to get through our own governance cycle and ready for approval. Medicare dances to the beat of their own ground a little bit. I expect that to be in July or August timeframe. They give us a 90 day window so any time between July and September would be a reasonable guess. I have no additional information other than that in terms of the specific timing. Okay, thanks. That's our question about it right now. Okay, are there questions from your board? I have a question about the 2019 clinical priorities. He probably gets me from there but the documents he's submitted. Particularly around the chronic disease management optimization and some of the goals there. I was curious if you could speak to whether there are patient education materials that you have recommended to providers and providers are choosing their own patient education materials or how that needs to play out in some of those issues. Sure, that's a great question. So with respect to the chronic condition management in some of those focus areas I would say it's variable. Where one care has selected in the past or currently a topic of focus areas or diabetes in the past hypertension oftentimes part of the work of those collaboratives is to identify the best of the best and try to align around them. In particular, that seems to happen within a health service area. So for example, it might be the primary care practices and the home health agency agreeing on the same patient resource tool. In other areas that we haven't focused on systematically there's a lot more local variation on that. And I'll just end by saying we actually have just announced in our recruiting practices for a learning collaborative through late 2019 and into 2020 that will focus on COPD and asthma and so we expect to see some of those resources emerge from that as well. Thank you. Part of that struck me, and my answer to the question is particularly for COPD, I've had some colleagues in that previous and that's from the program where their project was COPD patient education videos and materials and they in a very short period of time less than 18 months reduced their inpatient revisions through this patient education structure and involved both EDE, catch points in the EDE as well as the redesign in their care model, but it seems like that's an area that could really bear some fruit if the residents are found. Absolutely, thank you. I want to follow up with you guys on that as well. Happy to provide. And on the Dulce Project, I'm wondering if you could tell us where, I know the first one was in Memorial County, where are the other sites? I'm just talking to my colleague, I'm not at the rate when I was all of them yet, because they're still working on contracts, but they are geographically gross across this place. Okay, well I look forward to this learning about that. I have another time. Sorry to jump around so much, but. On the complex care slide, which is slide 16, when you were talking about the evolving, evolving repair model for 2020, I wonder if you could speak a little bit about how the blueprint for help has been involved in that conversation and how that interacts with the blueprint. Sure, that's a great question. So, one of the things that we've done, because in the current care model, the level one capacity that we've been given was going to be to the health service area, so that goes to the organization that holds the blueprint contract, particularly the hospital. We made sure in our stakeholder engagement process, as we were carefully figuring out who to make sure represent all voices to have the blueprint represented there. And then we have continued to provide them updates. We will be actually tomorrow in Waterbury with them sharing the final model. So, we have shared it internally with our team. We have not shared it publicly all of the final details yet, but as part of our process when we pull these town hall meetings, the way I'm envisioning those occurring is that we'll focus a little bit on current state, quite a bit on future state, and then really turn to the web care clinical consultant and the blueprint program manager to help take over that conversation around how we then prepare what does our community need to do to really be ready. Do you have a question? I'm almost done, but not quite. In terms of the innovation fund, I think this is a really interesting idea, and it reminds me of one of the things we tried to do in STEM, which was have that innovation fund to try and push down innovations to the local level. I was curious how you're setting up the evaluation of each of the funded projects and what you'll be looking for. Yeah, fantastic questions. It was part of the proposal. We asked for initial plans around the evaluation. We asked whether one care resources, the data and the support could be a help to that and in some of that we looked like. We also asked each applicant to speak to both sustainability and scalability programs because those were two core values that we felt like were critical. We didn't want to fund something that was great in a short term but really didn't have an opportunity to be spread or sustained. So within that, we are just finalizing the contracts and have them on the door and we will be working with each of the successful applicants to better design the evaluation. Generally speaking, each of these programs were selected and funded for 24 months and so we've got pretty good period of time to be able to track the data. Each program does have applicants identified as we mentioned this before. And then lastly, could you connect some of what you've been talking about today to the specialist title funding because I didn't exactly see how those feelings connected. So I apologize for not making that explicit. So as I mentioned earlier, we originally had $2 million in the budget and we diverted $1 million to fund several different initiatives. So a half a million dollars towards that first bullet of their mental health payment reform and a half a million dollars to add to the innovation fund leaving a million dollars to be allocated. It is then allocated to those four next sub bullets down around looking at the consultation model to improve access between primary care and specialty care that invented pharmacy model, a chronic healing disease initiative as well as the episodes of care variation analysis component that doesn't have a tremendous cost associated to it's more internal resources right now and then the design work to be able to kind of something next year. Thank you. So this question is I'm trying to figure out whether I don't think it's flashing green light but I think I'm wanting to know if it's a flashing orange light or a flashing red light and Todd last year in one of his testimonies said that when he negotiated the APM model that one of the existentist recipes concerned about was precaution. And so I'm looking at some hospital data that is all adapted that profiles could be medicated contribution to hospitals and NPR for 16, 17, 18. And those year over year increases were 3.9% 16 over 15. Negative 2.2%, 17 over 16 and 3.3% 18 over 17 but if you don't include diva if you add in diva which is around the time it's a lot of flatline. And if you look at the appropriations in the state budget for 2019 and 2020 you don't have data hospital data actual data but is, I think we said at the beginning 70% of the Medicaid population there could be a different one here is the cost of this, if going forward state contribution to Medicaid is basically flatline. Sure. I think it's a concern. And when I think about the cost to the all parent model I think the all parent model isn't in itself a solution but can be. And that's where some of the regulatory and rate alignment can come together in a way. There's coordinated efforts to push on the right payer program to the right ways to yield the sustainable financial resources going into the delivery system. I think it's a nice vehicle to start talking about the cost shifts. It is a concern. It's not new under the all parent model. I mean the same thing would have been occurring at the service paradigm. And I think it's something that we should all be talking about and looking at but it's very much dependent on state funding most during what goes into Medicaid and that should alleviate some other points on the financial system. So I think that as we got everything cropped up and running we have some stability operation at least in these programs. Now I really wanna focus on how do we make this work long term? And there's a couple different angles one of which is just keeping the providers on the table which means providing the right financial resources. And then let's talk about the cost shift and how the all parent model could be a force for good to address it in a coordinated fashion. So I wouldn't say it's a red light or I would sleep over it every night but I think it's something that we need to spend more time talking about as we can evolve into I guess the second half of the all parent model and have enough under our belt to move forward. Yeah, I would agree. I think it's more like a blinking yellow, right?  I think that if we could truly get to an all parent model and not an aggregate parent model then that would be one of the ways we can start to have good policy discussion about how do we wanna finance all parent Vermont and how much we're sharing that we wanna sugar out among public private sectors. And I think that I do think this model on what Vermont has undertaken does present the opportunity to have that kind of good dialogue with everyone starting to have some aligned incentives around total passive care over all of the population growth limits. And I think that's really how you have to do it. But I recognize the legislative cycle and the funding cycle. And that doesn't always jive of what we're trying to achieve while we're on as a state for the all parent model. I promise to answer kind of right into the second part, which may not be of any work, but it seems to me that when the federal government is going to mitigate money, they have a part of that form that is an economic relationship among states called the FNAP system. And by the Vermont here or in the states to mitigate money, it's done in a way that in some communities are dependent, Medicaid up to 16% of their NPR and others is down as well as 8%. So the payer mix is really critical. And so I'm just wondering, and seeing that they all their approach is probably the place to deal with this and from the point of the playing field among possible areas, does that make any sense to you? It certainly makes sense as a component that we want to consider in a very complex issue. So again, I look forward to the opportunity to talk about this in more depth and the moment that's on the area of expertise of mine. But any ways that we can think about in a more holistic way, all of the costs going into the all payer model would have been put in an aggregate payer model to an all payer model. I'm all in for doing that. I think it's essential to be a success long-term on this program. My last question is about the QAQ benchmark plan. That plan hasn't changed substantially in my understanding of us in the last few years. And I'm wondering whether you might have suggestions certainly not for this year, but for 2020, but for 2021 of changes in the benchmark plan that might be aligned it on what they would be with your reference. Are you referring to the actual Trans-Rate Review process or the way that one can contract school? What about the QAQ plan? Or the design of the package? I don't know, I confess I have not thought very much about that. I don't know, Sarah, if you have any of those. I think actually, you know, as we partner with the commercial payers, including Google Cross Blue Shield, but I'm also successful at working with MVP down the road, that would be a great opportunity to have that kind of discussion, right? Because now you've got the payers who are responsible for the benefit design. I believe a lot of that is federally mandated. So I don't know how much state leadway there even is on changing the benefits, there's probably some. But, you know, you're always going to be worried about affordability, so anything you add, you know, in one year in which the premium's being paid, are we really going to get offsetting costs to keep that affordable or are we adding nice benefits that will pay off in three or four years, the consequence of which then is you have short-term premium that's high, the fear is it becomes not affordable to those who need the cover. So I think that's where it becomes very complex, very quickly in my mind. As my understanding of CNS has enhanced the profitability of states who have returned to the planet and that we make you enjoy it, that it's got the actor of the leader or CNS would include it. You did one last question on my answer, that's a great question. I just have one question, Sarah, you outlined a lot of exciting initiatives and pilot programs that you're doing and something has hit us, you've heard me on a lot of scenes and hopefully, you know, millions of flowers have been moving from this event, but I also can't put all the water and fertilization that's required for all those flowers. So I'm just wondering with the resources that you have, have you ensured that each of these initiatives gets enough support and assessment to really, at what point are you perhaps going to be, how do you figure that out as it being, what are those initiatives? Because they all really do sound exciting and there's so many of them, I don't know how they're going to manage all of it. So this is actually a scale back, but we have a lot of things we wanted to do too. And that's the reality. So we are constantly making decisions about where we think the best leverage points are, what are the various interests of our network, where can we edit things and really learn critically from them through a vector evaluation processes or making critical decisions about large scale investments. We rely on really thinking holistically about population management. So part of what has changed at one here in the last year of show has been that in my role, we're really trying to align our, like when all we work with our analytics and informatics infrastructure to make sure that we are using our data most effectively through prior decision making. And if you were sitting in my office you'd hear me saying all the time, what do we stop doing? How do we know when we try something that's not working? Or where we need to divert resources in other places? And I think frankly we're probably 12 to 18 months away from having really good answers to that question about we've given enough time and energy to figure out these other places we need to drive more focus and there's some things we need to step out from or let go, I don't think we're quite there yet. And so in that respect, it's really our population of endless, our clinical consultants, our regional commission representatives, the medical director, all being out there, having conversations, pushing the priority areas forward and making sure that we get tremendous levels of feedback from all of our participants to really set those directions. Just gonna go for the comment. I'll just add a comment from my experience back in other states working in capitated systems. You know, when you're trying to do popular, so eventually you're trying to improve the cost in the aggregate of a population, you have to have some discipline to stay focused on the areas that really move the mean. And it can be so easy to fall into chasing the tails because a lot of times in healthcare the tails are really sad and people have really serious illness that they're dealing with. But the role of the, and there's parts of the delivery system that are set up to try to meet those needs. But we have to stay focused on what will move the mean for the general population. That's how we're gonna really impact the cost trend overall. So we know we wanna focus on the 15% or so that have any complex care. We know there's certain diseases that are prevalent that can really impact cost. And then we have to be also rigorous about take stock of our learnings. And sometimes good ideas just equally executed or start the right time to bring about the kinds of changes that will make it successful. We just need to note that maybe reserve for another day but move on to something that will be more impactful and I think that's the challenge. As we build a portfolio of activities and we're able to start bringing in and experience analytics, did they work or not? We should be able to be even more focused on where we sort of place our bets for our scarce resources to make it impact. But it takes some time to sort of get to that point and it does take a lot of rigor among all of the stakeholders but sometimes it's difficult. There is, I can make the line go over. So, just to kind of finish that point, this is a list that actually it's truncated but these are the areas of interest and priority that our Population Health Strategy Committee brought forward to inform both the request for the innovation fund proposals and then the rigorous review process. And so the reason I put this in here in the appendix is to show you that cream of the crop in those top three get almost every area of interest and so strategically they were critically important. If we move forward we're gonna be making more careful and judicious decisions about which of these levers we think can have the biggest impact on quality of care, our promise, cost, control, et cetera. So the 2019 area of interest, are those that also have to be criteria that you've met your own internal initiatives against? And this is the innovation fund that we, to some degree, don't have. Yeah, they should have done that. They have done it quite well. More or less equally prioritized, you know. Was that the rank ordering of the, that is not a rank ordering of them. And so I would say it varies a little bit depending upon the depth of experience we have with other programs as well as here, it really was, in respect to the innovation fund programs, the context, the community, the cost, you know, how viable we thought this was all coming together. Sarah, I had a little bit different variation on the question that you just asked me about. I'll try to build a different point in that. What has been your biggest disappointment as far as an attempt to see a return as far as food health and savings when the soil and the climate just went right and it wasn't successful? And then on the flip side, what has been something that has really surprised you with how well it grew? You've had a day-long conversation there. I think, I wouldn't say it was a failure, but I think a key learning for me, something who likes to focus on change and how to engage people successfully in that, is that within our complex care program, I think I underestimated the lift to get that capacity-building framework off the ground. And so I'm very excited about where we're moving with that peanut model change. And I think I have seen this tremendous change in the last couple months just as we've had those focus groups and people talk to their neighbor and their colleague in a different community. I think that is facilitating the kind of change that I might have guessed would happen a little bit more organically nine to 12 months ago. On the other side of things, in terms of a huge success, I'm trying to pick just one here. I guess I would say from a broad perspective, it's actually the way that we are advancing our analytics and our approach to be able to meet the interests and the needs of our community. So that's not to say we don't have a long way to go. This is complicated and ever-evolving, but I think that the tools that we've been able to bring forward in the last 12 months so our performance report package that goes out that shows a deep dive on utilization trends as well as cost. And then our elbow-to-elbow support by implanting these populations of analysts with local community teams to actually analyze this information and drive some of the local decision-making has been very helpful and has more rapidly than I might have anticipated resulted in change at the local level. So identify a problem, a driver, and jump right in with a program or initiative and a lot of them have been related to ED utilization, for example, on coordinating services around our substance use disorder challenges in the state even though they're... So I would add one. I was pleasantly surprised by the uptake of the rise from our communities. I think my concern going in would have been that there was something unique about St. Albans that all the stakeholders were just ready for rise from on to be successful and would that really translate out into other communities? And I think I've been pleasantly surprised by the interest and the commitment and the energy that was created in communities not St. Albans. So that would be my surprise if you were to ask that question to me. Chair Maul. Do you have any inertial data that shows that there's been successful spares like reducing the obesity and things like that? I love the rise program. Talk to me in 15 years. That's exactly my point. Thank you. With that, we're going to open it up to the public for any comments or questions. Yes, Jim. Thank you for the presentation. So I picked up on a few things. One of them would be I'm applying this and just to say so if it doesn't really apply, but you were talking about the segmentation issue, but I think you really meant it as focusing. And I couldn't help but think that often of that policy, and if everybody is in, it makes it easier to work the segmentation because the population is in that you're going to segment. But maybe that's totally different than where I can see a chicken in the head now. I get it. I was looking at something else at the same time you were talking about what you were talking about. I also noticed that therefore that attribution, and this is the other factor, you were talking about not really being able to take everybody in at once. I thought I saw in some of your statistics that you felt like you were maxed out and you would have to trend it out, how you bring people in because the rollout takes time. So that was something else that I was always trying to figure out is how you would actually pull that many people in at once. There's a trend line to how you'd actually roll out and meet the needs of that many people all at once. It's not going to happen in one year. Were hospitals ever promised that they would get all the money back that they invested? Or was the model really from the beginning, you invest a certain percentage or come back? That's a good outcome. And the other one I'll mention again is workforce. The whole time I was listening, I couldn't help but wonder what happened to, as workforce leaves, because I still hear stories every day of people that are leaving Vermont at work in healthcare that has to affect the capacity to coordinate care as they're falling apart underneath us as we're trying to coordinate the care. And I'm seeing statistics that pick up on that. At least here, maybe they shouldn't be here. Why didn't you include grandparents? When you mentioned legal aid parent child centers and some of us like me are grandparents and we're in that taking care of the children equation. Hello, we're there, but we weren't in that one. The list you mentioned, or are we? That's it, we thought about it. Do you want to try to address them with that? Sure. Thank you so much, Bill, for your comments. I think to start from the reverse order, I tend to try to use the term caregivers to more broadly describe the populations. And so you're right, absolutely. Grandparents, aunts, uncles, there's all sorts of members that are in that group. In terms of your workforce question and folks leaving, I think there's several strategies that we need to look at more together as a healthcare network. And one is really around telehealth. How can we leverage the workforce in new and more efficient ways by using technology differently than we do today? And then the second is really thinking about are there better ways that we can have flexibility under the all-care model to think about the types of services that are provided so that at each kind of strata of the healthcare system, people are working to the top of their license or their education. So we don't have any plans in place yet, but one of the areas that we are planning to explore as it pertains to the complex care program is really the community health worker approach. And we know that it's being used in different areas under different models. And so that may be a way to extend the reach of a supportive and knowledgeable workforce and free up nursing, for example, or social work. With respect to your question on attribution, I would just say that from our provider network perspective, the faster we get individuals that they already care for under this model, the more aligned the system and the easier it becomes for them to provide care in a coordinated fashion. So while there might be some operational challenges to us centrally at the ACO for standing up in programs, they're outweighed by the benefit to our provider network who wants to make sure that they're caring for everyone in the same way. And really quick, as I said, that's as long as the hospitals were never promised any, getting any of their money back. That's just the model that's in place. Getting that money back in the home share savings is totally independent on the homeless of their HSA and the homeless of the ACO overall. So it's a decision that they all make moving forward. Yeah, I was just, you know, part of the hospital commitment to being in this journey is it's common with the mission and what they're supposed to be doing is good stewards of resources within their community. So I don't think anyone was thinking that this was going to be a dollar for dollar return, but it was going to be some return, hopefully through good performance, but more importantly, quality cost of returns in other areas that may not be counted financially but that are equally beneficial to the communities where they are. Hey, other comments and questions from the public? Yes. I had to hold in for my program for quality home care comment and maybe an offer for Sarah. If I heard correctly, Sarah, were you starting an initiative with 30 days follow-up following mental health hospitalization? Here. We are looking at exploring a partnership with the designated agencies to address multiple quality measures. I use that as an example, yes. Did you see in some extent of work with our insurer partners, both Blue Cross Blue Shield and MVP aggregating data and working with the DAs and several key stakeholders and produced a final report about a year ago? We'd be very happy to share that information, those recommendations, conclusions and in keeping with the Flower Garden analogy we tilt that soil and we're happy to share our work, so. Thank you. Other questions and comments? Thank you very much. I see your presentation. Thank you. Now we're going to shift towards an update on what happened this year in the legislature when it relates to the topics that bring them here more to lunches. Hello, I'm Susan Beard. I'm the executive director of the Green Hat and Care Board and I am going to run through some of the updates that we have in this legislative session. Two things, I'm going to introduce the team here but these are not the only folks who have actually helped me get through this session to help us get through this session. It was many other folks on the Green Hat and Care Board staff and I don't want to leave anyone out. So the first thing I want to say is a bit of a disclaimer is that this is very early to be reporting out what happened at the legislature. They did, as you all know, measure last Wednesday, but I've been in touch with legislative council and what they do at the end of the session is they pretty much scrub all the bills and make sure they cross check every thing so that what ends up in the final bill actually is what happened. With what we have today, for you, I'm quite certain that not being a significant individual change, but I wanted, I actually talked to Jim Carby this morning. She wanted me to share that disclaimer, especially on S31 and S73. And if there are any significant changes, I will update you if that happens. Some of these bills have been sent to the governor. As I said, some are being still scrubbed and a couple, I think, have actually been signed or have acted on this. So first I want to introduce the team I'll actually acknowledge a little bit. This is Sarah Kenzler. She is the director of strategy and operations at the Green Out of Care Board. Amron Aberdailey, who is an associate general counsel at the Green Out of Care Board. Christina Glofflin, who is health policy analyst at the Green Out of Care Board. And Jean Stutter, who is our financial director, essentially runs the budget at the board. So, I'm going to start. So, we're going to start with S31. And this is the price transparency bill. And it's really split up into a couple of different parts. It actually started out as a genuine price transparency bill. But then it became so much more, which often happens in the legislature. So this is price transparency, a limited oversight from the board to psychiatric hospitals and HIV consent. So in terms of, and the patient bill of rights, as you can see, you can read that, but basically the patient bill of rights in this bill was updated and also extended to other parts of the healthcare system, or the healthcare organizations. The other very relevant point of this bill to us is that the legislature has given the board limited oversight of the psychiatric hospitals in the state. So that includes the roundabout retreat and it includes the state psychiatric hospital. And the area which we may look into is scope of services volume, legalization, discharges, pay or miss, quality, coordination with other aspects of the healthcare system and financial condition. And consider ways to get your hospitals from the integrated into system, like payment and delivery reform. On the next slide, I want to just skip over that slide. And then there's the next, and then the next slide, which we can just go through. So these are, again, following along the theme of price transparency, the Green Mountain Care Board with other interested stakeholders. Essentially, we'll be looking at a report that we did a few years ago, that was an Act 54, I believe, reported 2015, where we looked at the viability of a price transparency website using heat cures. And it was a quite extensive report. The legislature just wants us to go back and look at whether there are other states who are now doing state-wide price transparency websites and update other transparency issues that other states are doing. And then number two is essentially simplified billing, which isn't very simple. I did talk with our data folks on this. This is a pretty big lift, but we will attempt to provide recommendations regarding a more simplified way to present a patient bill. And we'll also be working on insurance on that. So I also wanted, the last part of S31 is around HIV consent. And I kind of asked these folks to present, like, what, this morning? So I kind of put this on them at the last minute. So I'll just say, Sarah Tinsler was the point on S31 and especially around the consent work that came out of the legislature. I'll have her set up a little bit of the background and then maybe get the highlights and then go from there. Thanks, Susan. So as the board will make you remember, through our work previous, we set Vermont's policy for patient consent for information sharing electronically through the Vermont Health Information Exchange through the V-HI through our authority around the state's health information technology plan. And during the 2018 legislative session, the legislature requested from Diva that they develop our public recommendations for the plan to be presented to the board and that they would make a proposal to the board to consider whether we would want to change that policy. And previously, Vermont's V-HI consent policy has always been up in policy whereby patients are required to affirm that we consent prior to their information being shared electronically through the V-HI. That's not consistent with what most other states in the country do, but there are a few others that do it that way. So the board received a report from Diva in late 2018 and that was presented to the board in January 2019 from Diva with this research and findings that provides national projects and some context around our current consent policy and has the functionality of the V-HI and the utility of the V-HI. So the board was in late with the early spring preparing to receive a formal recommendation from Diva. However, the legislature in March asked us, and this was specifically from the House Committee on Health Care and the Senate Committee on Health and Welfare, to pause in our process about the legislature themselves through this issue so there was extensive testimony in both Senate Health and Welfare and in House Health Care from March to May to consider various stakeholder perspectives on this policy and potential for changes and the legislature eventually decided themselves to add this into S-31 and to basically set the consent policy themselves so this will no longer be part of the board's authority and S-31 in its final form included language that requires the H-I-T plan to include a policy that's passed by a soft out consent. So there was some movement back and forth between the houses around the timeline for doing that. Actually, Christine had the old switch to the next slide. Thank you. So the final piece that came out of the legislature was that this change would be implemented by March 1st, 2020 with notification to consumers at least on prior to that and our coordinated implementation effort and public communication effort led by D-BUT in partnership with the Health Information Exchange Student Committee and a variety of stakeholders that are part of our best community and more broadly interested in this issue and the board's role was drilling down to receive periodic reporting and updates from D-VA on that implementation effort so we'll be receiving updates from D-VA by August 1st and by November 1st and we'll be able to put in conjunction with the update to the H-I-T plan also if you never look first with the final reports to the legislature and to the board by January 1st. And are there questions? I think we should have questions for each bill instead of waiting until the end because we might forget by the time it gets. So how do we guarantee that health care advocate has the proper role in trying to work on that implementation strategy so that we're not backward at the end saying that they have to play their role in that process? Thank you. So the health care advocate is actually specifically mentioned in the statutory language and it's a little bit convoluted right now and so there has to have been a final version of this bill posted so I'm looking at the House Proposal Amendment, the Senate Proposal Amendment, the House Amendment and then also the House Proposal Amendment to that proposal amendment. So the health care advocate is specifically mentioned in the statute. You know I don't know that season keep going and I'll come back to that after that. Yeah they are called though. So they're called out specifically as D-VA is required in their communication and public education efforts to ensure that patients fully understand their rights and that they have people to go to when they have questions that ensure that that's taken to account and that includes providing contact information with the health care advocate. There's not a specific mention prior but I know that D-VA has repeatedly testified and I think that this is an area where the board will certainly continue to ask them questions as they provide us updates about the health care advocate and other stakeholders, particularly stakeholders who testified that they opposed to this change would be included in the stakeholder group that will work through the implementation of the process and actually figure out how the public education materials are developed and how the process itself will be implemented. So D-VA has testified repeatedly that they plan to include a very diverse group of stakeholders for a variety of views but I hope that we will also be asking more about that in our next meeting. Call with all of you to be working with me. Absolutely. Can we skip over S-73 because Michelle actually made me an example of it. Sure. Just so you agree. Yeah, we'll go to S-73. This is another one of the bills that is not been scrubbed or finalized by the council but I think these bullets will give you a general idea of where we are going with this bill. So the bill is actually a licensure bill. We started out as a licensure bill for the ambulatory surgical centers and through the House Committee, there was addition of some oversight of ambulatory surgery centers by the board and then this was going back and forth almost the last day and I don't think it would, they had like an informal conference committee but they did come to an agreement. So the first item is that the board shall obtain and review annualized data from the ambulatory surgery centers including NPR and the NPR reporting actually came out of House Bays and Means because they are concerned and would like to know the impact on provider tasks so they want that report so they can get information on the impact of the ambulatory surgery centers on that task. NPR, which may include data on ambulatory surgery centers, local services, volume, payor mix and coordination with other aspects of the healthcare system. If you look at the last bullet, I should probably start with that first. So the legislature wanted to separate out the new ambulatory surgery center, remounted surgery center versus the current ambulatory surgery center which is the eye surgery center because the licensure affects both of all ambulatory surgery centers in the state. So after 1-1-2019, or excuse me, any ambulatory surgery center that is in operation as of 1-1-2019, the board does not require to report after 2023 in our annual report. So that is a little confusing but it was a pretty elegant way for them to separate out these regulations. The board shall also consider ways ambulatory surgery centers can be integrated into state life and delivery system with one. And again, as I pointed out with our reporting in the annual report, in the remounted care board annual reports for 2021-226, the board shall describe the two reporting on ambulatory surgery centers. And again, bearing in mind that after 2023 the eye center will not be included in that report. So any questions? So we will go on to act 19. This is a three straight forward bill allowing reflected health benefit plans at all level levels. And this is called broad, metal, broad loading as opposed to silver. So it allows insurance to offer non-fault and I have reflected health benefits to individuals with small groups at all level levels in case federal in case federal costumery reduction came as our suspended and discounted. And I won't leave this slide but the essentially the board must ensure that this is complied with in our PhD process questions. And now another on a team of insurance, health insurance bills, H524, the health insurance of individual mandate bills. This was the bill that actually came out of house health care and this is the state's attempt in the legislature's attempt to protect ACA requirements and ACA and ACA work that is, that potentially could be at risk by the federal government. So I'm gonna turn this over to Amaran who was following this bill closely. Thank you so much. So H524 is the miscellaneous health insurance bill. I apologize for pushing so many slides onto one slide. I should have broken that up a bit more. But for the first section, as you may recall, the state individual mandate requiring the monitors to have health insurance become effective generating first one to 20. This was due to Act 192.18. H524 does not add a financial penalty but does add a reporting requirement for those individuals who file tax returns. Individuals filing tax returns wanting to file a tax return letter they have had health insurance during each month of the tax year. And I also added on here that this bill also adds an outreach requirement for DIVA in consultation with the health care advocate and stakeholders to conduct targeted outreach to those people needing health insurance coverage. They would be able to, DIVA is, would be able to use the information that's reported to the tax department to file tax returns and those taking back to us to cover each year. In addition to this, the bill also adds provisions in state law with the current new requirements under federal law and the court will correct. As you mentioned, the purpose of this is to ensure that protections on the ACA will remain in place under state law should the ACA no longer be in place or should provisions of the ACA change. So in examples of this, I put up here on our state law, we know that it vans on the pre-existing condition of exclusions and hands-on annual and well-time limits. This is on cost-sharing and requires covers for attendance up to age 26 years of age. And then also, excuse me, because we've pivoted licensed brokers from exacting payment from low-end or non-residents in health expense to share in arrangements. And the reason for this is that health insurance arrangements are not considered insurance. And the bill would not be appropriate for that type of broker fee. And then also, we have some additional reports and analysis for both the human care board and the emergency human services. For the three mountain care board, there's an addition to the board's annual report, which is the three mountain care board will quantify the impact of Medicaid and Medicare cost-shifts with un-conservative care on premiums. And the agency of human services is tasked with developing to that use for increasing affordability for health insurance and also evaluating options for controlling the amount of health insurance. And that report from the human care services is to 12-1-29-10. We'll just add, while I'm still on this slide, that the individual mandate amendments and the provision and adding provisions from A.C.A. to State law are effective in the 1-1-20-20 and requiring requirements to be prior to effective screening. And then one last portion of this bill is changes to the law's already on the books for association health plans. This bill places restrictions on the renewal of association health plans, limiting renewals in 2020 and years after, to only those agencies are in assistance, saying that those renewals would only be allowed if it is permitted under federal law, which the bill also implements. This portion of the bill will be in effective form. So H528, Rural Health Services Task Force. This was a bill that was in response to what's happening throughout the country and what's happening here in Vermont, specifically around Springfield and some of our other rural hospitals. It creates a Rural Health Services Task Force to evaluate the current state of rural health in Vermont and explore ways to ensure that the system is sustainable to provide access to affordable high quality health services. So the chair of the board is assigned to call this first meeting of the Rural Health Services Task Force together by July 1st. So we will be sending out notes to folks who are named in this bill. And I think it might be helpful. We don't have it here, but it's the student bill. There are about 13 named entities. And I think I'm just gonna run through the membership. So the Secretary of Human Services, or Jezebine, the chair of the Green Mountain Care Board, or Jezebine, the chief of the Office of Rural Health and Primary Care and the Department of Health, or Jezebine, the chief healthcare advocate and the office of the healthcare advocate, or Jezebine, two representatives of rural Vermont hospitals to be selected by the Vermont group by VAAS. We shall represent hospitals that are located in different regions of the state and that face the levels of financial stability. One representative of Vermont's FQHCs who shall be a Vermont licensed healthcare professional who will be selected by VAAS State Primary Care. One Vermont licensed physician in the independent practice who will be selected jointly by Vermont Medical Society and Health First. One representative of Vermont's free clinics. One representative of Vermont's designated and specialized service agencies selected by Vermont's health partners. One preferred provider from outside the designated and specialized service agency systems selected by the FQHC. One Vermont licensed mental health professional for the independent practice selected in a rural Vermont setting selected by the FQHC. One representative of Vermont's home health agencies selected jointly by the VMAs of Vermont and by Seattle Home Healthcare and one representative of long-term care facilities selected by the Vermont Health Care Association. So it's a pretty broad group of participants and we will be setting up our first meeting on June the 4th of July 1st. Any questions on that? Yes, who is the bill of president of the staff? Oh, thank you. The staff is designated as the green amount of care for it as well as the agency and community services. And we'll get to this later in the slides. There is a report that will be, or presentation that this task force will give to the committees of jurisdiction. Thank you for that question. Oh, so we skipped one. Act with me. It's basically a Medicaid cleanup bill that gives us more work. But we worked with Dita on this. They, because we overseen the previous database, they asked if we could take responsibility for this report, which was preparing the report on the impact of chiropractic and physical therapy program and its utilization services. So we did agree to do that. It also brings up some other areas in Medicaid, like navigator duties, and how can we share with that few others. And I believe that the report is not due until 2021. So, I see, yeah, so perfect timing. So why don't we just switch seats, Michelle, if they can sit here. So Michelle DePri is the Health Policy Advisor at the board, and she was responsible for following and testifying on S53, which is now at 17. I'll just permit our unit. So as the board is well aware, we have been, staff have been working on several iterations of our primary care spending metric for sub-pagina, and we will continue to produce the primary care spending based on our total cost of care analysis for the all care model purposes. But for Act 17, we're going to be working with staff. It's between our staff, remember Roy and Diva, so it will be me and Dimi, and at this point in the situation, and we're gonna work together, and I sort of think of this bill in two parts. So there's the current state, and then the future state. So the current state is us sort of looking at categories of professionals and determining the percentages allocated to primary care based on the decisions that are made to come from a working group that will occur this summer. And so we have our first internal fat meeting next week. And that will be to sort of look and list out based on the bill, the stakeholders that we need to reach out to, who should be included in this working group, and starting to sort of collect and put together, luckily we've done a lot of this for other primary care work, all of the existing definitions that we have in Vermont and nationally, sort of starting to look at those and call for better information, bring it to the working group, to let them sort of weigh in on bits and pieces of where they might think that procedure could work for a minute, or where we should take something out that is currently in the systems. And then the second piece of this procedure is an analysis of potential impacts of different methods of achieving increases in primary care spending in future years on that rough list. This came out right at the end. And so it's likely that we will be working doing some literature review for this piece and sort of just thinking more broadly on sort of future state, if we are to increase or if the decision is that increasing the primary care spend rate in Vermont makes sense, but what will that look like and how it will impact all of these things in the future? It's a very quick summation of like a seven page bill. So if anyone has questions, I'm happy to answer them. This list is just some other bills that are introduced this year are still alive because it's the first year of the biennium. You can see the list for yourself. Okay, this is passed. Yes, thank you. We did not pass and they're still alive. They could come back next year. And these are our reports. I mentioned quite a few of them as we walked through the bills. So now I'm going to turn it over to Gene Stetter who's going to give a very high level overview of the budget path. Thank you, Susan. So the first graph on the left, what it shows is that the Green Mountain Care Board stayed in alignment with the governor's request to level fund our budget for FY20. And now you can see that our total appropriation for FY20 is as low as it's been since FY15. The biggest change for FY20 from that is in terms of which funds are available for our use in FY20 due to the new 1115 waiver and the subsequent cap under the investment. GMC is investment number 45 and the investments under the waiver. The decision was made that AHS is too close to the cap to for us to receive global commitment funds for FY20. What the legislature chose to do with that is there was a conversation about what's the best way to manage that change. The legislature took a lot of testimony and ultimately decided that they wanted to keep the current 60-40 ratio where the state pays 40% and the billback fund or essentially the industry pays 60%. The legislature felt it was important to keep that percentage shift. So the legislature increased our global, our general fund dollars to offset part of what we lost through the billback. So from that, what you can see is that our general fund appropriation went up and the billback fund also went up. There was another scenario if our general fund had been kept flat with the billback fund would have increased that much more. So that was the legislature's best thinking about how to receive. So within that, what that required was Kevin and Susan to really manage our budgets and absorb increases, the normal and customary increases in salary and benefits in order for us to become global funded. So that this bill was responsible for that. What's just with you? I found the information that fell for the overall global commitment cap in the representative urgency board. I couldn't find anywhere, so the cap relative to the governor's recommendation for the commitment that's $20 million for future appropriation of which the legislature, this section, appropriate additional global commitment might have been handled with some other benefits. So there's still maybe $12 million more in there. That's kind of yet behind the place where this cap on investments is established so that we can understand where we fit in order to get the arm piece of it is really interesting because of that investment cap. Do you ever find it in your house? Thank you. There's two kind of pieces of the answer to the question. There is, I was reviewing testimony to the legislature and there is no reference to the sub cap to the MCO investments and pressures that they're experiencing that's pushing it, but I did not see a correlation or a reference to the specific cap in the bill either. The second piece in terms of, I realized that I was making the assumption that global commitment for the purposes of the state of Vermont is a blend of general fund and federal funds. Because we are considered what used to be known as an MCO investment, we're a 50-50 match. What's different for the Vermont care board is when we received global commitment funds, it came blended. So we received both the general funds and the federal funds from AHS. What happened with this change for the Vermont care board for fiscal year 20 is the agency of the governor's recommended budget had all of those funds, the general funds and the federal funds, they were the agency of human resources. So they kept both the federal funds and the general fund. And I think that's in part is what the legislature tried to address and making it not a dollar for dollar, but it's close to the general fund. Thank you. Okay, other questions from the board? Is there any board reports? Is the board open up to the public? No, that's it, thank you. Okay, at this point I'll open up to the public for any questions or comments. Seeing none, is there any old business to come before the board? Seeing none, is there any new business to come before the board? Seeing none, is there a motion to adjourn? Good move and seconded to adjourn. All those in favor? Nope. Mike Barber, would you call the roll? No. Yes. Thank you. Yeah. Yes. Yes. Yes. Thank you everyone, have a great rest of the day.