Good afternoon and welcome to the Green Mountain Care Board meeting. My name is Coven Mullen chair of the board and I'm going to call the meeting to order. The first item on the agenda is the Executive Directors Report. Susan Barrett. Thank you Mr. Chair.  Is that better? Okay. That on last Friday, May 6th, the board received and began its review of the proposed rates for major medical health insurance plans offered to individuals, families and small businesses in Vermont in 2023, including plans offered on Vermont Health Connect. For the individual market, Blue Cross Blue Shield requested an average 12.3% increase with plan specific increases ranging from 9.7 to 16.3%. MVP had an average 17.4% increase with plan specific increases ranging from 9.7 to 24.2%. In the small group market, Blue Cross Blue Shield Vermont had an average 12.5% increase with plan specific increases ranging from 9.9 to 16.1%. And for MVP, an average of 16.6% increase with plan specific increases ranging from 8.9 to 19.8%. The hearing, the board will conduct public hearings on the proposed rates on July 18th and July 20th. And they both started at 8 a.m. Also, the board is scheduled an evening public comment period or public comment forum from on July 21st starting at 4 p.m. Both the hearings and the public comment forum will be held remotely. And the board will also designate a physical location which will be available to members of the public. More information on how to attend, both of those, all three of those sessions will be posted on our rate review website. Right now, starting yesterday Friday, or actually starting Monday, May 9th, we opened a public comment period. So we'll be accepting public comment on an ongoing basis from May 9th until July 21st of 2022, this summer at 11.59 p.m. Comments may be submitted electronically through our rate review website, which is on our on the GMCB website by email, by US mail or by phone. And again, please visit the rate review website for more details on how to submit a public comment. All of this information will be summarized in an FYI fact sheet on our website. And if anyone has any questions, please reach out to me or Kara Christ with with those questions. In addition, we have the ongoing public comment period regarding the next all pair model. The board encourages the general public to comment on a potential next model with CMMI on an all payer model. And at any time, give us that feedback. We're sharing all of that feedback with our partners at the governor's office and AHS as they are leading the negotiations on the next potential model. And then lastly, I want to announce that we have the posting for the opening on the Green Mountain Care Board on our website as just as a reminder that processes run by the nominating committee in the Department of Human Resources. So the link to that those that posting is on our website and please follow the guidance in the link if you have questions regarding the posting. And that looks like I have covered everything. I'll turn it back to you, Mr. Chair. Thank you, Susan. The next item on the agenda are the minutes of Wednesday, May the 4th. Is there a motion? So moved. Second. It's been moved and seconded to approve the minutes of Wednesday, May 4th without any additions, deletions, or corrections. Is there any discussion? Hearing none, all those in favor of the motion, please signify it by saying aye. Aye. Any opposed, signify it by saying nay. Let the record show that the motion carried unanimously. With that, we'll go right into the business of this afternoon and I'm going to turn the meeting over to Marissa Melamed. Marissa. Good afternoon. Thank you, Mr. Chair, members of the board and the public. My name is Marissa Melamed. I am Associate Director for Health Systems Policy for the board. I'm going to walk you through our staff analysis of One Care Vermont FY22 revised budget submission. We do have a potential vote notice today. I'm joined by Michelle Sawyer, who is Health Policy Project Director. She's going to walk you through several of the slides. And Russ McCracken, staff attorney, who is available for legal questions or to help with the motion. If they could just turn their cameras on, it would be good. Thank you, Michelle. Just one minute. Thank you, Russ. All right. Let me know if that's not showing up the way it's showing up. Great. All right. So just the agenda real quick. The first several slides walk you through the revised budget process, which I reviewed last week. I'm not going to review that again, but I left them in here just for references to the relevant section of the rule. What we are going to walk through today is key areas of staff review that we looked at with the revised budget. We are also going to take this opportunity to give you sort of a status update on the budget order for $22 as a whole. And then I'll turn it back to the board for discussion, public comment, and a potential vote on the one area of adjustment. So again, these are the reference slides, and I'll take you right to the areas of staff review. So the first one is the condition around the ACO benchmarking solution. So there was a request, an adjustment request on the language from One Care. So we've reviewed that and we have a staff recommendation. And this is the adjustment that you would vote on today if you choose. Other significant areas that we thought were worth discussing in this forum are the fixed perspective payment target and strategy reporting and what we are doing there. And then we're going to walk you through a variance review of the financial model and the CARE model. And again, this is a variance from the originally submitted budget that was approved in December to the revised budget, which is sort of part of One Care's full budget review process. And then at the end, we will go through the budget order status update. And again, most of this is details and sort of analysis that we wanted to share to make it clear and transparent. But there's only one recommendation that we have that requires board action. So to jump into the first area around the ACO benchmarking condition. So last week, One Care proposed these three changes. That's the text that's in black. So we have some comment in red on the staff recommendation around their proposed changes. So the first one says focus benchmark reporting on utilization costs and quality and remove patient satisfaction and engagement and evidence-based clinical appropriateness due to lack of available benchmarks. So One Care sent in sort of what they learned about collecting and reporting data in these areas. And they are requesting that we focus only on utilization cost and quality and remove those other two domains. The staff recommendation in this area is to leave the five domains in the condition. But we recognize that there are some added sort of complications around the type of data that's collected and how it's reported in the other two domains. So we wanted, so we just wanted to add some phrase there to allow for some flexibility. So our recommendation is to include the five domains but as sort of as available and appropriate. And the intent here sort of speaks to the second bullet point which is that we constructed this budget order condition around what we knew at the time and what we were sort of envisioning. But we've learned things since then about how this tool can be used and what's available. And our intent is to have flexibility around how the reporting is designed. So the second bullet point there from One Care says, excuse me, flexibility to work with selected vendor to identify specific measures based on available data and have a collaborative process with the GMCB staff to determine reporting and templates. This we feel is consistent with the intent of the condition and with the staff recommendation. So, you know, we accept this change. And again, but we would like to continue to pursue the five domains as available and appropriate with this in mind. And then the third one says, eliminate requirement for Medicaid and commercial benchmarking as vendors report lack of industry standards, low data availability, consistency, and high cost. So our staff recommendation here is to not eliminate this equal requirement entirely. And actually the One Care slide says to eliminate it, but the language that they gave us doesn't actually eliminate the requirement. It's what is, well, you'll see it on the next slide. But we accept their proposal, which is basically to amend the FY22 requirement to be focused on Medicare only. But One Care will work with the GMCB to continue to pursue the feasibility of options for benchmarking Medicaid and commercial programs. We just understand that it's, there's not an easy ready made product like there is for Medicare. So with that, we came to this proposed language, which is that I'll just walk through the changes here. The first one is that we're going to, we're making it clear in the first sentence that we're asking them to implement a Medicare ACO benchmarking system in this, in this first year. So we added in Medicare, we took out, built for each payer program. Again, around the five domains or five key areas, we added the phrase as available and appropriate. So that provides some flexibility for the staff to work with One Care and their vendor to, to figure out what makes sense, but, but not letting go of the fact that we are interested in information in these five domains. The next change around the specific requirements like, or what we want the benchmarking system to do. We did not change A, the intent is to allow the ACO and the GMCB to assess One Care's performance against peer ACOs or integrated health systems. B, we changed the wording since it was a little bit awkward. But the idea here is that the benchmarking system will enhance One Care's ACO level performance management strategy, including integration of best practices and priority opportunities, identified through benchmarking and peer networking into One Care's quality evaluation improvement program. The idea here in plain language is basically that A is we want you to collect this information around benchmarking. B is we want you to do something with it. Show us how you are sort of bringing that into your quality evaluation improvement program or integrating it to your committee structure, however One Care makes those decisions. And I don't think it's a little bit of a wording change, but I don't think there's an intent change here. We want them to integrate that best practices piece. C is that the benchmarking system will improve ACO regulatory reporting and performance assessment by providing the benchmarking comparisons to target at least semi-annually. So this was also part of their request through their vendor vetting process. They made a case to us that quarterly was not going to provide us any additional or any more meaningful information than semi-annually. And we agree with that. And so we'll allow this change. Again, if we found that there could be some value in having them report more often, this could be changed in the future, but we agreed with that to start. So again, the final paragraph is just making it clear. This is a Medicare benchmarking system. It's going to start in FY22 as a test year. They have to propose it by March 31st and present it at their revised budget presentation, which they did. And then we changed the, well, we added the final sentence, which did come from One Care's recommendation, which is that they will gather additional information on the feasibility of expanding benchmarking for Medicaid and commercial populations. And they will provide a written update to the GMCB on these options by October 1, 2022, which is the time of their budget submission. And this may be, we may learn over time about this during the budget review process, but we wanted to be able to discuss it. So have an initial proposal by October 1. So these are the proposed language change. So the next steps here is that the GMCB will vote on the amended language. One Care is in active contracting with the vendor, as they discussed last week, to get that finalized. They can move forward. And One Care is working with the GMCB. We're working together now to develop the reporting template that that work has already started. And the first report is expected per the budget order by the end of July. And I want to just date here that we do expect, or we're leaving open the possibility that this will be iterative, that, you know, we're supposed to have an initial template by the end of June with a formal template by, or formal report by the end of July. It's possible there could be some iterations of what this looks like before we get it right. So I'm guessing you want to leave discussion on these areas until the end, but I'll just pause here in case, since this is the one area where there's actually board action, I don't know if you want to discuss it now or wait until we've gone through the full discussion. Does any board member wish to discuss it now? If not, we'll just keep going. Let's just keep going, Marissa. Great. So the next area of review is around the fixed perspective payment levels and targets reporting. So really, all that we're doing here is specifying changes that we would like OneCare to make in the way that they report percent of fixed perspective payments. The order requires us to approve or modify and approve the commercial FPP targets, which we've not done, because we would like OneCare to report it a little bit differently than the way they have. So I put the budget order requirement up here just, you know, for reference, but what we need to do is make sure that we're kind of on the same page around the reporting, and I thought it was worth sort of presenting what we're looking at today. So I'm going to explain the change, and then we will include it in the final reporting manual for FY22. We've already sort of started kind of working this out and talking to OneCare about it. And again, this is informational. No board action is needed here, but discussion is welcome if you have questions or comments. So just a little bit of background. There have been different ways of reporting FPP. And through this condition, the staff's working to align the reporting and ensure a shared understanding of what the inputs are. Fixed perspective payments also reported through the hospital budget, and we want to make sure that we sort of understand how the relationship there is there, because obviously the dollars are going from the payers to OneCare into the hospitals. And so we see this in all of the different processes, and we want to be able to align them. So just in the most simplest of terms, there's been quite a bit of discussion around whether we are doing the top calculation, which is total fixed perspective payments and comprehensive payment reform payments over total cost of care or only reconciled fixed perspective payments and CPR payments over total cost of care. I believe, or my recommendation is that we want to see both reported. Also, in OneCare's financial sheets, they report total fixed perspective payments, including the Medicare arrangement. But then in the FPP reporting, they sort of just break out the reconciled. So we just want to make sure that we understand what we are looking at. So this slide is what OneCare reported, I think back to us originally back last July around their target for fixed perspective payments and then their progress they presented this last week. We asked them clarifying questions around what's in or not in there. Obviously, if you look at the Medicare line, they are not including the reconciled Medicare AIPVP because it's at zero. However, their financial statements, it is in there. And so we want to see both reported. So this is the slide that we presented in December. And I did update it with the revised budget numbers just so you can sort of see. But the difference sort of in the way we're reporting it is we pulled the these inputs, basically the numerators and denominators directly from the OneCare financial sheets and did the calculations that way. And then we noted, okay, is this reconciled or unreconciled? And then for example, like in the commercial line, ours comes out a little bit higher. I think because we are including maybe the SVMC pilot, I have to double check. But we want to make sure that we're aligned in the way that this is being reported. So essentially where that brings us is that we want the report to have both reconciled and unreconciled FPP. We want to include either the numerator and denominator or make it clearly footnoted to the financial sheets, what is included in those calculations. Then I think there's an opportunity to adjust the target slightly if we think we if that is what we want to do or that's what we need to do to approve it. Do we want to have a reconciled and unreconciled target? And then and so in order to get there, the staff's going to issue the reporting manual as specified in the budget order, you know, with these changes included and have OneCare sort of report to the new template. So again, no board action is required. But we wanted to give you an update on what we were doing here, because I think in order to really look at those targets and have them be meaningful, we want to make sure that we all are clear about how that how we're calculating them and what we're looking at. So again, it sounds like we can save save conversation to the end. So I'm going to move on to the next area, which is the ACO budget and financials. So I brought back this slide from our December presentation, which is a reminder that the Green Mountain Care Board looks at the ACOs financials in two ways. There's the full accountability or non gap budget look. And this is an all in financial perspective. It captures expected total costs of care, pass through contract revenues, organizational, organizational revenues and expenses. This is everything. It's not in line with generally accepted accounting principles, because much of the revenue is the responsibility of third parties. But it's important for us to see everything that's sort of associated with the with the model. So this is one important look. And that's the big number. We also look at one cares entity level or gap budget. And this captures only the revenues and expenses derived from and incurred by the organization's operating activity in line with accounting principles. This allows us to understand one care as an operating entity and allows us to look at their financials in comparison or in line with their audit that they do turn into us. So this is a summary income statement. So that you can see the change overall with these two looks from the original to the revised budget. Many of the line items are rolled up. So I don't I would caution you against reading too much into each individual line. We just want to give you a summary look. The full financial sheets are available. We so we wanted to show both the entity, the gap view and the full accountability, the non gap change. So the full accountability change overall is one percent. It's driven mostly by finalized attribution and associated costs of care. This is expected and it's close to the original budget. One care presented and talked about this last week. The second major driver of the original to the revised budget variance is the change in payer program contract terms, which you can see a little bit more easily on the gap side because a lot of that revenue is associated one care operating activity, which which is not just an admin. It's admin and programs with an overall variance of nine percent, which is, you know, more of a significant change and the drivers of the change. I'm going to outline more clearly on the next slide. So so on this slide again, sort of breaking it into the two looks. The overall variance and the full accountability is thirteen point five million to one percent reduction from the original budget. Again, this is associated with updated attribution and associated total cost of care as the greatest variance driver and this type of variance is expected. This is why we do the revised budget because those contracts are not finalized at the time of the original budget, and so we are not going to be able to see kind of what the what the the estimated attribution needs to be updated and the numbers need to be rerun. But the the overall variance on the gap side is about two point three million dollars or a nine percent reduction and the final contract terms are the greatest variance driver here. So this this has to do with how one care made their assumptions. So the biggest change is in the Medicaid contract changes. So the original budget roughly assumed that the 21 terms were going to carry forward to 22. The 21 Medicaid terms would carry through to the 22 contract and that's how the budget original budget was built. So this means that the monthly payment to one care Vermont from from Medicaid is fixed perspective payment plus the administrative payment which covers the other programs such as care coordination, PHM programs, VBIF, and administrative costs. So previously one care was allowed to take a portion of the PMPMs and use it to fund their infrastructure and administrative costs. And the totals there are there was about 7.9 million in PMPM funding, 3.6 in in care coordination. A portion of that could go to administrative costs. I also wanted to note that there was the one care did not assume delivery system reform dollars in 2022. So 2021 they did receive those dollars that was not built into their 22 assumptions. But the rest of the terms were were roughly assumed to be the same. The final contract or sorry the revised budget reflects the final contract terms which looks a little bit different. And now the monthly payments that are being made to one care represent fixed perspective payments plus what is now called in the contract payment reform support payments. And those include care coordination, PHM payments. But the notable change is that those payments can now not be used to fund one care Vermont operations. They also they're in the final diva contract. They negotiated a $2 million diva specifics value based incentive fund which was discussed last week. And the total in payment reform support payments is reported at 6.5 million. So the takeaway here is that there's less overall in the contract. The PMPMs are less overall but all the money is directed toward providers and not one care operations. I'll note here that Medicaid was the only payer that contributed to operations in previous budget. The commercial payers or Medicare do not contribute to operations. So then the difference to fund the operations because the operational budget was kept level plus the cost of the benchmarking system is offset by the hospitals. And that shows up in two ways in the financial sheets. One is an additional 927,000 participation fees and basically the amount that 3.36 million is roughly the care coordination amount which is now in offset by hospital fixed payments. And again if you're trying to follow the math here it's not a one-for-one difference due to some other adjustments but I tried to keep the slide as clean as possible even though there's still a lot of information on there. So I think that gives you a summary of sort of the major contract changes from the original budget assumptions to the final. What we wanted to show here is just a little bit more detail and quantify some of the amounts that One Care presented last week. So the takeaway on this section is Medicaid contract changes are sort of a major driver of the difference between the original and revised budget. The operating budget is held level but it adds the cost of the ACL benchmarking tool which is as the board ordered so that could be implemented. And the VBI Act was funded as ordered. And so the staff recommendation here is to continue to monitor the financial terms of the budget order through quarterly reporting and there's no board action required. So next I'm going to turn it over to Michelle Sawyer who's going to walk you through the population health and care model updates from the original budget. Thanks Marissa. All right so condition 9d had asked that One Care give us final descriptions of their population health initiatives including their final care coordination payment model. Their initial budget described that the care coordination model would be shifting after receiving some network feedback. So with some stakeholder engagement they started to revise the model. Care coordination payments would be decoupled from the use of care navigator which was their software system and instead payments would be tied to accountabilities. Previously the care model was one in which providers could earn payments for care managing their patients using care navigator. So they're still incentivizing that care coordination for patients but it no longer do they have to use care navigator to receive those payments. And at the time the specifics were still being finalized and they would communicate it to us in the near future which is what they have done and the next slide we will compare the changes that were made to the previous model. So in 2021 and in previous years this program was available to participants meaning primary care physicians per bird providers which are the specialty non-pcp providers and collaborators meaning home health agencies designated agencies area agencies on aging and sash so they were all eligible to earn these care coordination payments. Those payments came through as monthly per member per month payments for care coordinated lives and they could also earn payments for care conferences that were held as needed. The payments were earned based upon the completion of care coordination tasks that were documented in care navigator system and it was based on the risk stratification of the patient they were focused primarily on high and very high risk populations. And the amount of the monthly payments were dependent on the care team member position so lead care coordinators received a higher payment whereas care team members received a slightly lower amount. So starting in program year 2022 the program narrowed its scope slightly to who was eligible to receive these payments. It's now available to primary care physicians home health agencies designated agencies and area agencies on aging so specialty providers are no longer included nor is sash. There are two types of monthly payments now. There is a monthly payment made that is based on the full panel of attributed lives so they receive it's a smaller payment but it's for a much larger population and that makes up 85 percent of the pool of funds that are set aside for this program and then these organizations through the attainment of certain quality measures can earn an additional 15 percent bonus payment that's made on an annual basis and that that 85 percent monthly PMPM is earned based upon completion of care coordination accountabilities so that looks like the submission of tri annual reporting to one care where they have to show that there is participation in cross organizational collaboration and shared care planning engagement with one care in their process improvements attendance at education sessions and ongoing subpopulation panel review and outreach. Next slide please. So we're going to dive in just a little bit more deeply because this is a very new model on how each one of those provider types how they earn these funds. So for primary care providers that monthly PMPM they serve as a capacity payment for member months again based on their full kind of panel of attributed lives and then they earn the 15 percent annual kind of bonus is available and it's tied to the risk adjusted total cost of care of their population. So for home health agencies that monthly PMPM is based on the proportional share of the 2021 care coordination payments that were earned by home health agencies through their use of care navigator in the previous year. So they're looking back to 2021 saying what we're you know what did you earn in in that year for care coordination payments and they're kind of basing 2022s payments on that number and then they can also earn an annual bonus that is tied to the rate of inpatient admissions for attributed lives after a home health visit. So encouraging to keep clients out of the hospital and living at home. Next slide please. And then designated agencies their monthly payments again these work a little bit differently they're based on their proportional share of the total dollar value of claims care claims for care provided by designated agencies to attributed lives in the Medicaid program and then their 15 percent bonus that's available is tied to primary care physician engagement for their attributed lives that they are actively care managing. In the area agency on aging their monthly payments are based on the proportional share of the 2021 care coordination payments earned by AAAs through their use of care navigator similar to how it worked for the home health agencies. And then the 15 percent bonus is available tied again to primary care PCP engagement for attributed lives that are being actively care managed just like it works for the designated agencies. Next slide. So the key takeaways we would love we were going to continue to monitor these initiatives and revised care coordination model. There is an evaluation that one care described to us that should be completed in the summer of 2022 so we'll be very interested to hear the results of that evaluation. And at this time no board action is required. I will hand it back to Marisa to review the budget order conditions. Thank you Michelle. We thought this was a good opportunity to just take you through the budget order conditions and sort of let you know the status again we monitor the conditions and sort of the completion of the conditions throughout the whole year and this process actually isn't complete until we're into the next year when you get performance results. But I think it's helpful to periodically let the board know where we're at. So conditions one and two are around the ACO benchmarking system. We've talked about this. This is the only area that requires a board action which is to vote on the amendment. The FPP levels and targets condition is number three and this is you know we're going to put this sort of updated reporting template into the reporting manual and then monitor it. Condition four around scale target initiatives and alignment. We received contracts and forms that help us analyze scale target and alignment and this is formally reported or GMCB formally reports about scale under the all payroll model agreement in June and that will include 2021 final numbers and preliminary 2022 scale results. The condition number five is around the benchmark trend rates. We you know require the contracts to monitor this and so we are you know we were viewing the contracts for that. Sixth was a new condition around working with Medicare Advantage plans in Vermont to develop scale qualifying programs for FY 23. So we don't have an update from one care about that at this time just a reminder that it's in there it's something a little monitor I assume ask about in the next budget process if we don't know anything before then. Condition seven was around the risk model and seeking approval if there are changes. We asked them to report this in the revised budget no changes were reported again we monitor it. Conditions eight nine and ten are around notification of any material changes to the budget the revised budget documentation the revised budget presentation these we can actually mark as complete. Condition eleven was around the operating expenses not to exceed 15.3 million plus the cost of the benchmarking system. The revised budget is in line with this condition and we monitor the operating expenses through financial reporting quarterly. Condition twelve was to notify the GMCB within 15 days if one care uses reserves adjust participation fees or uses line of credit. So this is as needed. We do note changes to participation fees and hospital fixed payment offsets in this presentation. So we're considering reporting you know that that's the reporting the reporting is done in this process if there are additional adjustments to participation fees as there have been in the past those would also need to be reported that's new in this budget order as well as the other things in here around use of reserves or line of credits we monitor that throughout the year. One care is to submit their audited financials as soon as they are available that's anticipated in August 22. They also need to submit their most recent IRS form 990 as soon as it's available. I haven't quite confirmed the date but I don't be sometime in the summer. Condition 15 is any revised proposal for population health management programs if not fully funded. They reported the way the contract worked out for the DVA VBIF and there are no other PHM changes that were reported in the revised budget in terms of funding and then there are some of the programmatic changes that that they described and Michelle described. 16 is to fund the VBIF or other pre-funded clinical quality incentive program at a minimum of 2.24 million that number was chosen because it's level from the prior year. There's actually up to 3 million dollars that's available for the VBIF. This is the 2 million DVA funded and the 1 million one care funded. Again we monitor this throughout the year. 17 is the blueprint and cash funding which again we monitor through financial reporting and it is budgeted as ordered. Finally condition 18 around administrative expenses being less than the health care savings. This condition has been in the order for several years. It's over the duration of the agreement and we do expect to have an assessment from one care around this condition at the duration of the original agreement. I mean at the completion of the original agreement in 23. For that concludes our remarks. I would turn it back to the chair for board discussion questions, public comment or potential vote and I'll note that we did not receive any written public comment on the revised budget. Thank you Marissa. I'm going to open it up for a board discussion and questions and go in reverse alphabetical order so starting with board member Walsh. Tom. Thank you chair. Good afternoon everyone and thank you Marissa for walking us through that. I think I just have a quick comment really. I'm very much interested in the benchmarking project. I'm pleased that they were able to find a Medicare benchmark process or a vendor who does that. I'm a little not discouraged, but I'm looking forward to further work in finding a way to benchmark commercial and Medicaid. I feel like it's unlikely in searching that they found nothing. And so there's a process for going through an assessment of potential vendors. Systems engineers use this process. It's a formal process called an analysis of alternatives. And it recognizes that you're not going to find a best fit always. And I can send you a link if you're interested Marissa that we can share. So there's a process for going through this to identify the best available alternative and I'd suggest that that process be used to identify a way to benchmark with one cares performance with commercial and Medicaid participants. It's important because you know in in the US we spend hundreds of millions of dollars a year on pet food. We'll pay well for things that work well. And the NORC report suggests that one care could be doing some things well. And so paying for it would make sense. But with only financial data like you presented today, we don't have a sense of how well they're doing. And so the benchmarking piece is fundamental to assessing how well they're doing. And I just want to say strongly that we really need that the ability to benchmark. That's it. Thank you. Next we'll turn to Board Member Pelham. Tom. Well thank you Marissa and team for all this effort. There's one or two areas I'd just like to emphasize. If you could go back to slide 12. I really forgot to put a slide numbers on here. Can you tell me what the header is? Oh it had to do with the FPP targets. It's condition 3A and 9J. There you go. So I just want to kind of share my observation about this. You know I'm very happy. So in one care's presentation and I'm reading directly from their presentation they one care said that one care and the commercial partners continue to discuss an unreconciled fixed payment concept for potential implementation in 2023 that's pertaining to commercial payers. And then more recently you know and this is a good thing Don George the head of Blue Cross Blue Shield has said we must turn determinately toward value based payments in global hospital budgets etc. Again in a more recent letter he said as we look to the escalating numbers on hospital and drug cost I am resolved to my conviction that our health care reform efforts are more important than ever to rein in cost increases and ensure broad access. So that's a good thing. During our hospital budget review last year we had Dr. Brumsted relative to commercial perspective payments say in our quote well I'll just say that we would be first up in any commercial payer wants if any commercial payer wants to come forward with actuarial derived total cost of care targets and are willing to allow us to have the portion of the premium that would flow through the ACO to support care management the first in line he said and why I think that's important is that obviously the head of the largest commercial insurance entity in Vermont and the head of the largest provider entity in Vermont agree that they want to get FPP and it's and we all understand that it's a vital underpinning of health care reform but the problem is you know what are the facts on the ground and the facts on the ground are that as we went through our last hospital budget cycle there was less than one percent of the payments to hospitals were FPP and if you flip to the chart here I think it's like the next slide maybe here you can see down there for the insurers total fixed payments as a percent of expected total cost of care is one point one percent so the good intentions of Dr. Brumsted and Don George are there but the results aren't there and so as we head into the current rate review season where Susan said at the beginning of the meeting we're looking at you know you know average increases in the 12 percent 17 percent range and then we have a hospital budget process coming up after that you know I'm hoping there's opportunity in this tense you know tense efforts ahead of us to move the ball substantially on fixed prospective payments in the name of reform and in the name of cost containment and so if you go back to the previous slide we were just at my assumption my takeaway from this is if you look at the commercial payment expectation for 23 it's a 23.9 percent and for 24 at 44.9 percent I'm going to make the assumption that if that actually occurs if during the next year or two years but especially during this coming rate review and hospital budget process that if we get to that level of commercial FPP that one care can handle it that we're not going to be in a situation where one care says whoa we you know we were hoping we would get there but um we really can't handle it it's not something that we're prepared for I'm going to make the assumption that they are a pair of prepared for because it could be a vital part of the the workout of our current tensions between the ability of reminders to pay and the the demands or hopes of insurers and and hospitals so um that is that is my comment on observation on this I just I just want to you put it out there that I as one board member am going to rely on one care's ability to deliver the goods at the projection levels that they have in their presentation thank you Tom next we'll turn to board member lunch Robin Robin I think you're muted so Robin um I'll pass over you and go to Jess and maybe you can sign off and sign back in Jess yeah I think she's actually I'm guessing she's doing that unfortunately I can't kill too much time here because I don't have specific questions or comments other than a thank you to Marissa and team and um I I'm like the others I'm really looking forward to that benchmarking analysis and just you know to see that evolve so that we have some capacity to understand how they are doing relative to other ACOs so I don't have anything more to add here at this time but thank you great Robin can you do a sound check can you hear me now we can go ahead I don't know why my teams does this so much so much so I have two areas I wanted to just touch on briefly one is the care coordination payment changes I really appreciated the clear explanation of the changes in the program from staff and I'll be very interested to hear more about how the evaluation went and would love to maybe get a bit of a deeper dive during the budget process this fall I also am interested to see how the benchmarking proposal evolves with commercial and Medicaid and support the staff recommendation and the changes there that's all I had great thank you so much Robin so next we'll turn it over to public comment does any member of the public wish to comment at this time and I'm going to start with Charles Becker hi um so my name is Charles Becker I'm a new staff attorney with the healthcare advocate can folks hear me we can congratulations on your new position great thank you and I understand you're from Rutland so you got to be a good guy I am from Rutland uh well actually I live on the other side of the mountain in Stockbridge but I work out of Rutland so okay um I didn't have any questions or comments about the presentation per se I mean I certainly had plenty of questions but I'll bring those back to my colleagues um I just wanted to briefly introduce myself to the board if that's okay that's great okay hi so like I said my name is Charles Becker most people call me Charlie um I started with the the healthcare advocate in mid April um but I've been with the Vermont legal aid and the disability law project since 2016 as you said working out of the Rutland office so I represented Vermonters in the southern four counties of the state um Vermonters with disabilities and seeking access to care and developmental services um certainly enjoyable work uh frequently rewarding challenging work um I really enjoyed getting to know my clients on a personal level it was you know that kind of work is is important to do um but when the HCA position opened up it seemed to me it was too unique of an opportunity to pass up um to be able to engage on a statewide level uh in policy discussions and helping Vermonters to get access to high quality affordable healthcare and so I put my name in for the position and and here I am now uh looking forward to doing rate review with uh before you all um and uh in helping my HCA colleagues to fulfill our other statutory obligations and proceedings before this board so thank you thank you it's a pleasure to meet you and an important question how often do you get detoters uh at least once a year they they opened up just recently so I'm gonna I'm gonna let the crowds cry uh quiet down a bit and then I'll I'll sneak in I stopped for a maple creamy on my way back from up till your last week it was great ah very good with that um we'll ask for a public comment on the uh one care discussion does any member of the public wish to offer a public comment at this time if not um does any board member wish to make oh Marissa not not a public comment obviously but I wanted to add um we did not receive written comment but we did um meet with the HCA um I meant to mention that um and we went over the revised budget and met um Charles and um they did give us some questions which helped to inform this review process so I want to make a note of that great thank you so much Marissa at this time does any board member have any further comment or does a board member wish to make a motion I'll move that we um amend uh one care Vermont's fiscal year 22 budget order by modifying condition one as recommended by the Greenland care board staff to limit the benchmarking tool to Medicare data for the first year and make the other conforming flexible flexible changes as outlined today okay is there a second oh second is there any discussion hearing none all those in favor of the motion please signify by saying I I I any opposed please signify by saying nay but the record indicate that that motion passed unanimously does a board member have another motion I don't have another motion is there any other motion required Marissa no I do not believe so okay so with that I wish to thank uh Marissa and Michelle and Russ and uh like everyone else I'm really looking forward to seeing the feedback from the benchmarking analysis and I'm hopeful that the early results come in before July 9th so with that is there any new all business to come before the board hearing none is there any new business to come before the board hearing none it's going to be a rather short and brief meeting is there a motion to adjourn sound moved second it's been moved and seconded to adjourn all those in favor please signify by saying I I I any opposed please signify by saying nay have a great rest of the day everyone enjoy this beautiful Vermont spring day


Happy birthday to the NHS, 70 years old, we're so, so proud of every single member of staff, all your hard work, we are eternally thankful for everything that you do and personally you've helped me and my family hugely along the way so a huge happy birthday NHS. Pemwyth hapus i'r NHS yng Nghymru yn yr benig ar hodd help ychydig roi'n i fel teulu a pemwyth hapus ni'n brod iawn o hwnna chi bob un i'n ydy'r staff yn yr NHS. Pemwyth hapus, happy birthday!


And thank you for inviting me, particularly, thank you for allowing me to select to choose a topic because there's a lot one can talk about at the moment. I thought about talking about the Irish presidency of OSCE. I thought of talking about various aspects of the EU crises we're looking at in the Euro and then the Schengen onwards. But I chose the Arab Spring and the implications for the European neighborhood policy because it is, in my opinion, the most significant development in the second decade of this century. And it ranks with the most significant development in the last decade of the last century. I refer to the breakup of the Soviet Union and the enlargement of the European Union. What happened here in 2010 is a totally new phenomenon, in my opinion. The former Soviet Union, the Soviet system collapsed internally, whereas what's happened in the Arab Spring, in the most striking thing about it, is the demonstration of people power. These popular uprisings are also very striking in that one they're not ideological. They have not been anti-US. They have not been surprisingly notably anti-Israel. And we have a very interesting development at King's College about three years ago. We started people, I think, all the Atkins Fellows. And these are 10 fellows from, we chose they're at doctoral level. We chose them every year. Ten from Arab countries and five from Israel. We make them work together in our rabbit war in the basement of the Strand Campus. We have them around the place all the time. During the Arab Spring, we had some great discussions, as you can imagine, because we had two very good Egyptian fellows. And what they used to tell us is, this is all about three things, they'd say, fundamentally. Freedom from oppression. They'd say bread, but by bread we meant a lot of things. It meant jobs, it meant the economy, it meant a whole lot of things. And the third big thing for them were the democratic values. Not saying which type of democracy, but the values of democracy. And I'm striking also that all this was brought about not just because of authoritarian regimes, not just because of youth unemployment and food prices and inflation and all the things we talk a lot about, but it was driven by a new phenomenon of the new social digital networks. Most popularly, we know them as Twitter, Facebook, and other forms of digital communication, which those of us who are more technologically minded, who are more technologically minded, will understand how this development is going at a pace. And it has fundamentally changed an awful lot that we have to discuss from now on about popular uprisings. Surprisingly also, the traditional political parties have played a very small role, hardly there at all. The other movements, like fundamentalist movements, were completely taken by surprise. Al Qaeda has not been involved, except as you might expect to some extent, some evidence of it in the Yemen, but that was to be expected. But it hasn't been a factor in the other uprisings. Egypt was an interesting case in point because it was not just the unemployed youth, it was the unemployed youth supported by the middle classes. But there is another new phenomenon which they all spoke about was the influence of Al Jazeera television, which has been a sort of keeping them in touch with what's going on elsewhere in the Arab uprisings. And this has been another new phenomenon. Now, I'm not going to analyse the uprisings, as I think it's a whole session in itself. And also, each country has their different characteristics. And you have Rosemary Hollis coming in Thursday week.  And no doubt, I'd love to hear her analysis of the mess we're in Libya. What I'll try to do is to give... talk about the European response to these developments. First of all, give an overall picture to talk about the implications for the European neighbourhood policy and to speculate a bit on possible outcomes. Rumsfeld's made a famous remark, he used a famous category once of known-knowns, known-unknowns, and unknown-unknowns. Now, this really applies to this situation. Somebody, a friend of mine, says it's the only remark he ever made in his career which contributed to promoting international peace. But that's really hard. But the first known-known is that nothing is going to be the same. And that another known-known, as if people power will for now on be a factor that we must politically take into account. A notable known-unknown is that nobody knows where this is going. And a big unknown-unknown is whatever, what new regional power structures are going to emerge from this. What types of leaders will emerge from this? You know, one can speculate when we come to write the obituary of the Arab Spring. Where will this democracy movement go? Where will it be? Will there be democracy-loving billionaires who've emerged in the Arab world as we found Soros in the experience of the 1990s and the impact that these democracy-loving billionaires had? Who will the leaders be? When we look at the history of revolutions we can't be very encouraging that things necessarily happen very quickly. Just think about 58 Hungary. Think about 68 Prague. Or more recently, think about 80, which we would say is Gadence. They all took many years to reach fruition. And the people who led these uprisings didn't achieve what they wanted to achieve right away, but certainly they were part of what ended happily in the end. I'd like to focus this talk particularly on the neighborhood policy. And the first remark I make about neighborhood policy is that the most successful neighborhood policy of the European Union was enlargement. And if you look at that success what would strike one, I think, is the soft power of the European Union and the basis of that soft power was a magnetism of the Union. And you can contrast this with the characteristic of America during the same period. And the American strength was the projection of hard power. A noudage that the soft power of the European Union was far more powerful and more effective. American hard power ain't what it used to be. I don't know that we're going, particularly after their adventures in Iraq and Afghanistan, that Congress will allow any administration to take the same route again. But European soft power is what we are looking at. And it has been an enormously successful phenomenon in the enlargement of the European Union. Since... I suppose I should make a relevant remark about also since we're talking about what made the process and what made this magnetism successful. There was an accepted doctrine that reform and democracy were linked with prosperity. This was accepted right across the board. And coming out of these debates with the Atkins Fellows, I can tell you, they now question really whether reforms and the type of democracy we have can lead to a sustained prosperity because they look to our recession, they look to certain... they don't have to come to Dublin to know that things are not exactly working out the way we thought they would. And so there's an added problem, I think, for the Southern neighborhood policy in that there is a doubt about whether this link between democracy and reform and prosperity is still so evident. I believe we can get around that, but I just mentioned that as a factor. It's a new factor as we see. But to mention the second aspect of the most successful was certainly enlargement. And the second was, let's call it, the Eastern neighborhood, which regrettably has been somewhat disappointing. But they will tell you, and I'll come back to this point later on, that a key problem has been the inability to offer membership perspective to these countries, to the six countries in the Eastern partnership, or what we now called the EAP. But the third aspect which we want to discuss here is the Southern partnership. And here there's a most unfortunate legacy because of our failure to pay attention to the nature of the regimes we were working with. And this now comes back to some extent to haunt us. The events in North Africa, therefore, have shifted the focus of the European Union to the Southern dimension. And we've had two very interesting communications from the Commission. In March we had the partnership for democracy and shared prosperity, which was an interesting document. But I recommend, and I'm no doubt on your working party, we'll be looking at what we call the review, which came out on the 25th of May. And this is, they called it a new response to a changing neighborhood. Now, it's all the usual things are there, building blocks for democracy institutions, rule of law, human rights, and civil society promotion and so forth. But there's a totally new emphasis on the next generation and a number of new elements. The most interesting for me is the creation of the European endowment for democracy. They said quite clearly, Cathy Ashton at the press conference said, this is based on the American model of the American endowment for democracy. And those of us who worked in the field know how effective the two wings of that have been the National Democratic Institute and the equivalent Republican Institute. And those of us who are working in countries like Georgia and Armenia and out there, the work that they did was far more effective, in my view, than a lot of our programs, because they were working to help create political parties. They were quite blunt about financing political parties that we would never have done. But they also were at very much at the cold face of we were working on things like constitution and all that, but they had much more freedom. The idea that Cathy Ashton explained is to have a much more aligned, much more like the American endowment for democracy. And this will be a new instrument. And it goes ahead with another new instrument called the Civil Society Facility. These are new elements. I will come back to talk about some detail a little bit later. But I noticed that the budgetary arrangements are perhaps as generous as you can expect what the commission is asking for. The current budget for the European neighborhood policy is 5.7 billion between now and the end of 2013. And they would add, propose to add a further 1.25 billion to this and an additional 1 billion to address urgent needs in the southern partnership. And the EIB is putting together 6 billion. And as you know, the EBRD now is enlarging and changing the mandate of the EBRD so the EBRD would also operate in the southern partnership. This is a swing of the pendulum in incremental development of European neighborhood policy. I'll be very brief about the history of where we are. What has happened up to now in the southern policy has not been up to expectations. I recall you bring back to your mind in 2008 when France proposed the setting up of the Union for the Mediterranean, the UFM. This was followed fairly quickly by the Polish-Swedish initiative of the eastern partnership. In fact, in terms of substance, what is being proposed now in these two documents that I refer to is a sort of a step back for the eastern partnership because most of what was there, not all, but most of it, has been on offer to the eastern partnership. Deep economic integration, free trade, mobility partnerships, come to that again later, but they didn't take to it. They didn't respond, except I'll come back to Moldova as perhaps one example. Perhaps I think with the Polish presidency coming in, this emphasis that we all talk about these days about the southern partnership, I think there will be a redress of that to some extent. The commission, everybody in Brussels certainly seemed to favour a single policy instrument and one can see the advantages of that. It makes the EU more visible. It harmonises what's on offer. Very importantly, and I can tell you for those working in the field, the action plans provide a sort of reform agenda and that was extremely important. It always felt to those who were working in this area. And the arguments there are still, I think, valid about trying to have a more or less single policy initiative. But with the emphasis now in the southern neighbourhood, is going to be on political reform, conditionality and what we call differentiation, so that each country will have very differentiated agreement and with a lot of flexibility if we see going through this excellent paper. By the way, the paper of the 25th of May is full of interesting ideas and I'm sure you probably will be very interested to see your analysis of it. Now, what are the problems and I suppose let's list a couple of the problems. The conditionality criteria here are not very well specified. I suppose it's very difficult to do so. But it speaks of suspension for those who fail to reform. And this is the thing which in our game we call positive and negative conditionality. And I noticed and if you'll allow me I will read from the paper of the Commission which says the EU will curtail relations with governments engaged in violations of human rights and democratic standards including by making use of targeted sanctions and other measures. Where it takes such measures it will not only uphold but further support civil society and at the same time apply a differentiated approach which will keep open the channels of dialogue with the governments, civil society and other stakeholders. This in my submission is a totally new departure in neighborhood policy. And I don't know how those who have to manage this thing are going to work positive and negative conditionality. It's to my mind it's a new concept and those in the field who are trying to apply this new concept I think will find it very, very difficult. That's a problem I would signal. Another aspect of the paper is that it doesn't deal with attitude towards Islamic parties. I suppose we all hope that the Arab League and so forth will move in a Turkish direction rather another direction but it doesn't seem to go with that. Another problem I think might be the notion which is through the whole paper of more for more. This is that you get more support. Those who reform more will get more financial support. This has, of course, is an interesting concept but it has its flaws. It could work I would suggest in Moldova where there's a willingness and a wish to reform and it would be a good incentive there but there would be no incentive at all to a country like Azerbaijan where they would just laugh. I think it was a joke because they're so rich and they wouldn't be interested. Then there's another aspect, the Palestinian Authority. Palestinian Authority in my submission is already a full partner of the European neighbourhood policy and the funding of the authority will have to continue regardless of the democratic deficit there for purely political reasons. It's the more for more and the positive, negative conditionality. I think it's going to be very interesting to see how all that works and it's hard to see, I don't know if other practitioners in this room, it's hard to see how it's all going to work out but there again there's a political reality which we must refer to is that all the European neighbourhood states' reforms depend on the political will of the governments who are in power and the ruling elites in those countries and they will want above all to remain in power and it's persuading the political elites to move in this direction is going to be one of the great tasks. I want to refer to the disappointment in the European neighbourhood, the Eastern neighbourhood policy. These are the six countries who I don't have to name and all of them have shown a regression on governance, democracy, human rights except with the exception of Moldova in my opinion and in the Southern partnership if you apply something, not quite the same criteria only Morocco seems to have made major efforts towards reform. You can say, looking at the Eastern partnership that there's been progress, limited progress on economic reform but a total failure in democracy promotion. The French proposal for the Union for Mediterranean that tanked very early on but there were unusual circumstances as we all know there was the Israeli war on Gaza. There was difficulty including Israel in the whole operation very hard to hold back you remember ministerial meetings weren't possible it really got nowhere and became a vehicle for just bilateral national policies. Now I'd mentioned one other thing about the legacy that we're dealing with. The EU and I referred to it a little bit earlier on but the EU and the US legacy of which we have to live down and work around are our relations with the dictatorships we were supporting and it's probably easier for us to get around this than for the United States. Further remark, I want to get back to the other thing but further remark about the Eastern partnership it's very, everyone says you know if only they had a membership perspective they'd have, everything would have worked rather as it did with the enlargement. I have worked in some of those countries and frankly I don't think even with a membership perspective that it would have made any difference because they were not prepared to move in a reforming direction and it's not just we talk about Russia but they all had, they all regressed towards more authoritarian type regimes. Now a valid criticism I think of the Eastern partnership and see how it applies to the south is that finality was never very clear. You know to share everything with institutions was fairly vague and I think if what we're going to try to do now is to avoid the mistakes made in the Eastern partnership we need to clarify the end game. We want to avoid the obvious mistakes I consider one of the great mistakes in the early years of our relations with Russia was the personalizing of the relationship with Yeltsin because he was a spent force from a fairly early stage and I don't think that helped because we weren't able to condemn the corrupt privatizations that took place etc. So there's an awful lot to learn and those of us who've been in the field dealing with projects it was an awful lot to learn from the management of projects and when I was leaving Georgia I had an interesting session with Shabarnadze and I sat down and I listed all the projects the EU had done over five and a half years there were an enormous number and an enormous number of consultants had been employed at an enormous expense and I said to the President look here we are there's one or two here that have worked but all the others they're all dead what do you feel that he said oh well you know but it was a problem that we were lot to learn from our failures in eastern partnership and in our relations with these countries because we perhaps were much too optimistic that reforms would be sustainable and of course the corruption came and other elements came and disrupted that So I think to come back to the clarify the end game I think in the new arrangements the goal will have to be clear and it has to be in my opinion association it has to lead to a clear association and it has to be a structured relationship with these southern countries whether they be it in Middle East or North Africa and it has to be with a time frame and we have to try to get our heads around a very new and dramatic situation we have to fight for your EU coherence in regard to this the big problems I've referred to already are the targeting of this assistance and the difficulty of providing more money at a time of budget restrictions May I try to answer the question why is the southern partnership important? I would give two immediate responses one is that our security depends on our neighborhood and our southern neighborhood but also prosperity depends on our relations with southern I go so far as to say that their prosperity their economic success is our security I just take one figure out of the sky because it struck me immediately when I read this we're talking about 800 million people in the neighborhood the population of the Arab League at the moment is 280 million and the estimate is that within 15 years that will nearly double to over 500 million and an amazing article the other day that I read said that the recent opinion polls are showing that more than 50% well, first of all more than half this population is going to be under 25 in 15 years time but that 50% of the youth want to emigrate now if we fail to create economic growth in the southern neighborhood and have real development there there's actually an enormous potential to destabilize our own countries now we know all the debate that goes on about managed immigration and we're not really handling it very well I know it's become awfully political with right wing and xenophobic parties on the growth in a lot of countries not just the Netherlands and Finland and elsewhere but maybe way to the next vote in France but it's managed immigration is absolutely fundamental but we will not be able to manage it if we don't deal with the economic development of our southern neighborhood countries the watchwords as we said political reform but also economic development and we can't not afford to address the economies of the southern neighborhood one consoling and surprising figure as well is that the European Union disperses half of the world's development assistance this figure surprised me but now it's all a question of what priorities we use in that exercise and how we target it and whether we can use the mistakes of the past not to make them again a little bit of political weather forecasting before I close what can we expect in the political weather forecast well I suppose there are a few obvious things you can say a more democratic Middle East and a more democratic North Africa it's going to be more unpredictable it'll be more unstable democracy is noisy but it's more enjoyable we know it's more enjoyable but we'll have to live with whatever comes out of this and do our best to work with whatever comes out of it another reflection and I think in Washington in the beginning to realize this and recognize it U.S. influence is likely to be much declined not just in the Arab-Israeli peace process that's another lecture but in a whole lot of other things in regard to nuclear Iran but take an example of Egypt which is now of course in the grip of the expectations of the Arab streets and the success of people's power there's a strong anti-American feeling among these people and it runs very deep they haven't at all the same anti-Iranian feelings as they have as anti-American United States is likely to follow Europe and having a policy towards that part of the world which is more value-based and Harry Clinton has already indicated this in a number of interviews and this creates a new situation for America's relations with the number of its present allies important allies take for example Saudi the Saudi for good reasons are beginning to feel threatened by this and by the whole developments locally I was intrigued to see the elements of many closer contacts between Saudi and China and I can see as one possible consequence of this is that there will be a new alliance between Saudi and China Saudi would certainly build its further close relations with the Arab monarchies and then there's the question of Syria which is probably the most difficult and maybe the one that survives longer than a lot of the others because the Syria is in a very strange position because the western community has virtually no influence there and you know how difficult sanctions will be and all that but I was also intrigued to see that Iraq and Iran have reached agreement to have a military alliance this is I can understand this from a Shiite point of view but it's also a very fascinating prospect that the Iran trained military American trained military is going to provide a very good complement the Iraq sorry Iraq trained American military is going to provide a very distinct complement to Iran's military capacity it's a very new world and we had a various experience at King's College with Turkey because Turkey I suppose that I would submit to you is going to become the most important strategic regional power in that part of the world and when about a couple of months after the foreign minister Davutogu became foreign minister he came and gave us a keynote lecture he came to my institute at King's and it was very very fascinating because he set up a totally new agenda for Turkey and we know some of the basic things of course no problems with our neighbors but what was very interesting is that he can see people said he was trying to restore the Ottoman Empire but he can see that Turkey is in a key central position to influence developments in that part of the world and I think Turkey should be the main ally of the European Union in that area because they have tremendous power and they want to see a secular and democratic I qualify that a bit but they want to see free democratic systems of government in the neighboring countries and they're very interested in the prosperity of the neighboring countries and they are a big player because this European neighborhood policy in the south operates in a very complex strategic environment you have the interests of Russia to the north and you have still the interests of the United States in the region particularly to the south so it's important to consider as one of the most interesting players and now reinforced after the elections of course they are much more confident on where they're going and much less looking towards the European Union though it's still part of their policy to try to achieve membership but we I think need to build on the ideas of partnership with Turkey and it should have really then have everything in it but membership if we can move in that direction but it's more important to have a political strategic partnership with Turkey and all that that entails and one I'm not going to deal with is Libya because nobody knows what's going to happen there and it could have serious consequences for the alliance in the real sense is we my colleague called it a bag of clubs it's no longer article five doesn't work there anymore and NATO doesn't even take a similar position it didn't even take a similar position in the United Nations on Libya and frankly they say it's a bag of clubs you can find a club for Afghanistan, another club for Libya and I wouldn't like to be Rasmussen I think he has a very difficult job there and it's a challenge to the European Union I think the biggest danger and the biggest thing to avoid is a political vacuum put simply the problems of this other neighborhood are for Europe not for the United States it's closer to Europe we're more interdependent our interests are more immediate and we have different strategic interests so we have to assume the responsibility I think for our for the southern neighborhood policy we can't there's no one else who can do it and I always will remain an optimist I think we should all try to be an optimist about post Lisbon Brussels I know we all know the procedures are slow there's a lack of a sense of urgency and when we even see how these excellent proposals are going to be processed there is a lack of a sense of urgency and so far regrettably there's no sign so far that this political vacuum is going to be met and that the European Union can meet the challenge but I hope I'm wrong in that assessment we need to move on what the crisis is within Europe of the Euro and Schengen and what everyone talks about nowadays is the crisis in leadership well I suppose it is very true but we must face some ways of getting around this crisis of leadership and this crisis of solidarity as we see with the Euro but let's hope it's going to be different this week with Greece look, if Germany is no longer the motor of integration the future then must depend on finding other medium and small size states of Europe to take the place of the original motor for integration I think we all hope and everyone hopes that Germany will remain the motor for economic integration and on the economy but there are a lot of other areas where I think we can look to medium sized and small sized countries and what's interesting is Poland and that's the next presidency of the European Union we had some very interesting meetings in London with the Polish foreign minister Rafał Siorkowski who is a very extremely pro-European character with very very good ideas and I think the Polish presidency will be a very active and fascinating one and I think we're going to get a lot of leadership from the Polish presidency that's just coming up so let's not be pessimistic there are a lot of forces against the negative forces are very evident but I don't think we should indulge in pessimism Lisbon was structured so that we could build a bigger boat a bigger and better boat more fit for purpose and look, if Lisbon is as good as it gets we just have to work with it we have to work harder with it we have no other choice and an awful lot depends I think on number of factors but there's the external action service David O'Sullivan spoke to you last January and he gave a very interesting outline the challenges facing him I have to say in this audience here one must admire the likes of David O'Sullivan and Catherine and others who have really made such a big impact in the European Commission in particular and others in other institutions and I admire David's courage in taking on this task but pretty simply it just has to succeed there's no alternative, it has to succeed I remind you that the three great challenges he said in his speech was one was neighborhood the next challenge is the Middle East peace process or Middle East peace and the third was to project European interests in the new global order of the new global world the new global order of economic and political giants is to project Europe in that world and European interests in that world of the United States, of China and of India there's an enormous task there but I want to sum up the European Union has a stark choice in its neighborhood it's either to be in the vanguard of change or again be behind the curve and on the wrong side of history I think the events in North Africa particularly have demonstrated this challenge and it's the challenge to develop a clear strategy it must rise to the the EU must rise to this it's a historical challenge by any proportions it must rise to the challenge of its neighborhood as I said we have to avoid the mistakes of the past and we have to give a priority to the political and financial political and financial priorities which are required to build a safe and prosperous southern neighborhood and I think it would be a great disaster for all of our countries if we fail to do so but the challenge is quite enormous and I'll stop there and look forward to the discussion