what the industry is scared about so you may see up front okay MVP costs this sigma costs this blue cross costs this and make your purchasing decision based on that but when you actually go into when you actually go to the hospital it may be a much different charge because there could be unintended claims that are or conditions that are uncovered which could then skew your results I think in the long run we think it's a great idea transparency is going to be helpful and it could help manage costs but at this time I think we need to see how it actually rolls out to actually see how effective it can be there could be huge changes in the way reimbursement is provided and the way that we're every carrier is paying hospitals and hospitals may have to change their charge masters as a result but at this time you know it's unclear how things are going to be impacted we would love it if we could identify how we benchmark against other competitors and use that to our advantage in contract negotiations on the flip side where we have an advantage that may actually end up coming back to haunt us so I think it's really an unknown at this point but we do want to utilize the information to the to the best of our ability to help reduce claim costs and unit costs at our hospitals yeah and I was also looking at it not against other insurers but against you know other provider types or different hospitals you know how consumers could use it to potentially low the costs and how you guys could help to support that that's what I was looking for okay yeah I mean that's a helpful point of feedback I can you know I can bring that back to our marketing team we do have a price transparent or shouldn't call it price transparency tool we have a shop a tool where you can you know a cost calculator right now that already exists they can go on and type in a service that you think is going to be rendered and it will benchmark the cost that you know facility A versus facility B or provider A versus provider B so that information is available and we do communicate that readily to our members in hopes of leading them to receiving quality care at the best rate the more that we can educate members on that and there's you know better utilization patterns and higher quality delivered that's going to help us contain costs or reduce costs or mitigate cost increases as much as possible and that's going to lead right into a more favorable premium rate so yeah we definitely support that and we do try to inform members about that comparison tool right when you enroll with MVP thank you um you talked a little bit about how you assess the pharmacy benefits manager and you know you didn't specifically say when the timing of when that contract comes up um and and you also talked about you know there's some big undertakings back end processing and things like that if you are ever to switch um but you know as you alluded to as well um in the blue cross filings there there was a significant change um and benefit to the policy holders with the change from their pbm and and just you know can you talk about when your contract comes up and the potential at that point of potential savings that is something that I would have to follow up with our pharmacy team about um what I will say is you know immediately when we saw that information from blue cross the first person I shared it with was our pharmacy VP to say you know hey I just want to let you know that this is out there and um here's the vendor that they're using and you know when we do come up for RFP or when we're having mid-year mid-contract conversations it's maybe worthwhile but at the same to bring up to CVS but at the same time we did look at the projected costs that we have for pharmacy versus our competitor using the URT information and what we're projecting for costs as a percentage of total costs I think that because of risk adjustment population differences I think that's the only reasonable way to do it um we saw that we're reasonably well aligned with them I don't remember which market it is but one market we were slightly lower than them on a percentage of total cost for pharmacy and one market we were slightly higher but on average I think that we're in the ball part with where they're projecting to be in 2022 okay can you talk about some specific cost saving initiatives you might have and when the impacts will be expected and how much you know potentially you know we could see I know there's a push toward um understanding low value care and I know that's something that the board asked questions about we're working on developing models uh and reporting in dashboards to help us understand the low value care that we're we're seeing delivered to to help reduce costs um we're also measuring when we have a value based partnership are there certain providers that are driving quality and lower costs on a risk adjusted basis than others um that's helping us evaluate who our network partner should be and um if there needs to be changes to our provider network but that also always has to be balanced with member satisfaction um because when you tell somebody that their PCP is no longer going to be in the network you know a lot of times that can cause a lot of member upheaval um so we we just have to do it very carefully and a very measured and data driven approach and you know what about specifically in fraud waste and abuse and saving money in those categories that is not an area that I go into a great amount of detail for um when something comes up my team identified an issue in our New York individual block I alluded to when Mr. Engel was cross examining me yeah we had some adverse experience in our New York individual block that we're remediating um that was something that we had identified in the Nexuario team and we brought that to the fraud waste and abuse team um that's kind of where I start getting involved with fraud waste and abuse is if we identify something we're very quick to address that with the fraud waste and abuse team but in terms of just strategy and development of new initiatives um that's not an area that I can speak to and comment on okay um I also want to take a look at exhibit 15 and specifically um we start with page 6 oops sorry start with page 10 alright so just looking at um the this premiums earned um on the first section under premiums it looks like um under the individual market it's about 94.5 million and the small group was about 113.2 yep and then flipping to the next page looking at the underwriting gains or losses um 2 million on the individual market so a little over 2% and 6 million on the small group market so almost 5 to 6% yep I want to contrast that to that page uh um page 17 so in the total line 11 um I guess in the total individual market you lost 40 million roughly and Vermont you actually had a gain of 2 million and in the small group you made 11.2 million and in Vermont um half of that came from Vermont it represents about 7% of the premium holders so you know I know you talked about you don't necessarily look back and give that money back but you know it just appears and um the prior year there also was some benefits from from the Vermont market that you know the Vermont market is subsidizing those losses that you have in New York and when you look to see that you're going about 17% in the New York market for premiums and 17% in the Vermont you know how can we think about you know giving those big gains back to the Vermont market and not subsidizing the surplus in such a way um to help offset I guess your huge losses you have in New York um yeah that's fair when we set rates we're setting them based on just the specific populations but I don't agree with the uh assessment that we're subsidizing losses across companies we did lose a significant amount of money in our individual New York population um I would characterize it there's a significant amount of adverse selection where two small populations kind of adversely selected against us and kind of sucker punched us and caught us off guard we're trying to remediate that but when we're setting our rates in Vermont we're only focused on our Vermont block of business and what we're actually seeing emerge in 2021 I recognize that our profit margin in 2020 exceeded our target but it's worth noting that in 2021 um we're seeing very unfavorable claim trend we thought that the second half of 2020 was post pandemic and we were experiencing pent-up demand starting in March we've seen a huge ramp up in services that we're based on the type of service we think they're deferred services um that were that were delayed until people were fully vaccinated when we look at our internal run rate reporting for Vermont block business in 2021 we're actually projecting to be about eight to ten percent behind our target and that's because of this huge ramp up in outpatient surgeries um colonoscopies laparoscopies well visits the associated labs that go along with them so if you were to look at our based on what we're seeing right now in 2021 if you were to look at 2020 plus 2021 I would not expect to see us exceeding target profit margins over that two year time period so um 2020 we benefited from reduced utilization in due to COVID 2021 we're actually feeling the exact opposite of that we had built in a pent up demand factor into our rates last year and based on what we're seeing emerge we were there is pent up demand we are right about that but the magnitude of it was incorrect it's actually far exceeds uh the actuals versus what we were expecting okay but we can't see that yet but we can see the benefits from 20 um common again but um okay on exhibit 17 we just need some help in looking at when we build up the 17% increase there's the component for the utilization um and medical trend which equaled the 6.9 you know on just the medical trend or the 7.9 on the trend from 21 to 22 but then when you go into the other risk factors where on line page 5 line 7 the 6.7% you know of which um L&E had characterized that as COVID and you specifically stated it wasn't COVID um how do we look at both of those increases so a 7.9 and then a 6.7 um how do I separate out like what is actually a trend and what is utilization in total because it seems like the combination of those two so if I look at I guess if you could tell me of that 14.6% how much would you say is is trend and how much is utilization so um the 7.9% is truly just our medical and pharmacy trend that we expect to see from 20 comparing 2022 over 2021 it's that additional year of trend um now the exact calculation of that I'd have to look into it if you know if everything ties out to the way you know our rates are developed but just that is actually an expected expected increase in cost from 2021 to 2022 the COVID I'm sorry yeah no that's fine that's what I'm talking about of which there was a couple small pieces that were related to you know some other things but the bulk of it was the COVID adjustment factor what that is getting at is um so if I I think maybe a timeline I'll try to like summarize in a timeline we're using 2019 data to set 2022 where it says you're aware um if you were to take and trend it to and what this is basically saying if we take 2019 trend it's 2022 and then we took our 2020 data and trend it's 2022 the difference in those two projections both of them would include 7.9% for 2021 to 2022 but the projected total dollar amount using 2020 data versus 2019 data is a 6.5% difference which we're attributing to COVID so it's more of a normalization factor to account for suppressed utilization and all the changes that we had spoken about in 2020 due to COVID so why can't we since it's just you know that's 6.5% would be roughly what 12-13 million dollars yeah and that I mean that exceeds um we would have lost about 4 million 5 million dollars if we pass through that full amount I think another way of thinking about that is if COVID didn't exist I think 2020 would have been a very unfavorable year we have lost a significant amount right but you didn't right so 2020 we just we just showed the gains and now it seems like we're saying we're going to have that come back as a COVID adjustment because of higher utilization more than what you gained but you know I just want to try to look at trying to offset some of that because in Vermont specifically forget what happened in New York we specifically saw gains in 2020 that you now seem to be rolling forward to say on top of the 7.9 to put in another 6.5% is really picking up some of that of which we already saw the benefit so you know I'm trying to look at how do we accommodate for that yeah I think that I wouldn't view the 6.5% though as just an adjustment factor to say you know this translates to of profit of 12 to 13 million I just I think I look at it as if we included that adjustment we would have been in the hole by quite a few million dollars and now we're experiencing this ramp up in claims in 2021 due to 2020 and if we are just take kind of a long view of looking at the data and this gets to the whole reason why we didn't want to use 2020 data if we look at this over instead of just choosing a 12 month time period we looked at our data over a 24 month time period I think what we'll find is that we performed adversely relative to expectations 2020 we we reported a profit of 3.5 to 4% I believe and you know as of right now we're 8 to 10% behind so if I'm hoping that doesn't persist and I hope that on average we get back to around a 1% you know 1.5% target profit margin and I guess we just need time to figure that out but as of right now I would I just would proceed with I just want to caution that 6.5% just kind of normalizes our projection for 2020's suppression and when we do that normalization we would actually be generating a loss in 2020 Would you say or if we were to look ahead to 2023 would you expect this 6.5% to come out in 2023 because it seems like we're again we got the 7.9% in total and then on top of that another 6.5% would that be potentially going to come out in 2023 So when we're sitting here next year I'm assuming we would use 2021 data to set our rates and what is not clear right now the type of services where we're seeing this adverse experience it appears to be some level of pent up demand where people are getting caught up from deferred services in 2020 until they're vaccinated what isn't known though is if this is just a new normal our job is actually is to try to project costs into the projection period if 2021 data is arbitrarily increased because of pent up demand we're an offset that we would want to make to account for that projection to 2023 if it's a new normal then that's concerning and that should be passed through to 2023 if we want to set a naturally sound rate but I am sorry and what about the theory of surplus reserves should be held to cover things like pandemics so whereas there actually was a benefit clearly in 2020 from Vermont not necessarily from the rest of your business and then we're adding in additional expected utilization because of withholds primarily due to COVID why wouldn't that rule through reserves that's what they're there for right this kind of unexpected normalize back in theory in 2022 2023 to not have those we have a working with New York State DFS who regulates our solvency there's kind of a type target range of percent of premium that we manage to in terms of reserves and we were at the we were in that range but we were at the lower end of the range in 20 heading into 2020 so even though 2020 was a favorable year we're still well within that range that our solvency regulators are recommending that we be within we're not pushing towards the top of it or outside of it if we're outside of that range I think that's where you start really having to assess what we should be doing to try to reduce premiums or make some adjustments but when you're in that range of the target range that DFS is established then that's where we then we don't have an adjustment to make for that OK, just one more question when you look at your reserves and surpluses in total do you look at it by what's contributed by market in total or are you looking at it just in total you know and the drivers there so because I'm just concerned with obviously the Vermont New York piece but how do you look at reserves from the contributions from each state I would have to work with our accounting our financial planning team to fully understand how they're allocating those reserves if they are being allocated by state I believe that they try to they kind of break them out based on where our total where we totally shake out in terms of percent of premium and our total reserves but I would need to work with them to fully understand how they're allocating those out and measuring solvency for both of them we've been charging though a consistent we've been adding in a consistent contribution to reserves into our rates and you know from year to year we oscillate but we haven't had huge profit years I know that we generate around 8 million of profit per share which is a couple of percentage points above target but we also as an organization we were concerned based on all the conversations we were having what's going to happen in 2021 with all the pent up demand that we were expecting to experience and it's coming to fruition so any kind of understanding of an analysis of reserves by state I would have to work with our finance team I actually do have one more question you know I guess you assumed the same number of people would be in your filing this year as it was to last year but that was before you saw the competitive rates in the marketplace your competitors rates which because of their your much larger rate requests compared to theirs the comparable plans are much closer and so I guess reflecting on that do you think you might lose membership related to to the plan based on your assumptions you don't know what your assumptions were when you built them but how does that impact? we're aware of how our premiums are stacking up based on proposed rates I think what will ultimately alter our decision is the approved rates you know consumers are going to purchase plans based on as long as consumers have had a positive experience with MVP we don't have a reason to believe that they would walk away from us if our premium rates are well aligned with our in the market if we're expensive for significantly more expensive we may expect to lose membership but if we're reasonably well aligned then we think that we should be able to retain market share ultimately what's going to matter is where does our where do our approved rates fall okay good thank you I'm also all right thank you thank you member lunge do you have questions I do can you hear me okay yes how are you today good thank you so I wanted if you could please turn to exhibit page page 5 I had a couple of questions related to your administrative expenses for beginning the individual market billing so in question 10 you included per member per month breakdown of billing related costs for individual and small group markets these appear to be the total cost not the incremental cost for assuming the VHC billing am I reading that correctly correct okay and then I believe in exhibit can also coincidentally on page 5 you indicated that the total amount you're estimating for the individual billing activities is 0.3 million and is it can you do this in your head but can you can you either confirm that estimate that that is $3 and 32 p.m. p.m. is correct or give us a revised estimate that seems reasonable just eyeballing these two figures that that seems reasonable and I don't have any reason to think that's an incorrect calculation I believe though that the data on page in exhibit 10 its material increases so the exhibit 8 in the exhibit 8 figure is the total cost yeah and exhibit 10 is incremental cost I think that's the difference yes and I was trying to understand the incremental cost from the new billing activity okay yep and I believe that our financial planning team is estimating that the incremental cost will be approximately $300,000 okay thank you I did have some questions related to telehealth and thank you for going over the DSR order and how that relates to the assumptions in your filing so hold on just one second I think it is exhibit sorry I made you guys wait doing this too that's okay before I ask you about this I should confirm so in exhibit exhibit for a page 10 include a telehealth exhibit which I want to confirm whether that is public or private or confidential before I ask you about it it's also exhibit 10 page 6 whichever one is easier for you to get to yeah so I believe exhibit for yep I don't I don't believe this is not confidential okay that's my understanding of exhibit for a so I actually realize that under exhibit for a I don't have the exhibit included so for in my binder it's exhibit 10 page 6 where I actually can see the exhibit there's a reference in exhibit for a I don't understand okay good I didn't I wanted to make sure I was doing everything on the up and up here so in looking at this exhibit which my understanding is this is an exhibit which details how you built your dollar 89 p.m. p.m. telehealth increase assumption is that correct correct okay and as you testified earlier behavioral health seems to be a primary driver of telehealth yeah yes okay and you also have an assumption in your filing related to mental health utilization being increased I believe the unit cost we're assuming an increase for mental health services there's parity rules that are parity laws that exist so we have to ensure that our contracts are aligned okay and so earlier you testified that one of the other drivers of the increased telehealth utilization was duplicative services yes and please relate to relate that to the behavioral health utilization and telehealth it's not something that we we have specifically called out anywhere so it is just I think overall though what we're experiencing is an increase in telehealth utilization more than anything else if you look at so the duplicative efforts which that there could be some duplicative efforts in there I can't speak to exactly how much of that is duplicative at this point this isn't this is something that we're talking about though as an organization is how do we identify these kind of services and ensure that we're providing quality care but we're not providing too much costly care mm-hmm okay so the examples that you gave earlier which were primary care examples is how I would qualify that you can tell me if that's not fair where would I see the financial impact in this exhibit we don't break it out specifically and I use those as examples we're seeing it not just in primary care we're seeing it in specialty visits dermatology phone calls, radiology things like that it's not just these aren't just primary care pediatrician behavioral health changes we're seeing them in all all kinds of provider types okay so when I look at this exhibit and if I compare the pre-pandemic average monthly allowed amount for office PCP you'll see that's the one to third column of numbers over when I compare the pre- and I add in both office PCP and telehealth PCP and I compare pre-pandemic which is I'm using the PMPM 29 61 which is under office PCP plus telehealth PCP is zero I have pre-pandemic 29 61 post-pandemic for office PCP I think 24 dollars and four cents plus $3.64 which is telehealth PCP I get $27.68 so that's in fact a $2 PMPM less post-pandemic than pre-pandemic am I reading that right I agree with that yes okay thank you and then for the you also have a category office other and if I do some a similar look I see a smalling so for again office other $11.21 PMPM telehealth other five cents gives me $7.26 post-pandemic $10.13 office other plus $2.05 gives me $12.18 so little less than a dollar increase total I agree with that the one caveat to provide though is post-pandemic in this case is second half of 2020 based on what's actually happening in 2021 we think we we were assuming that that was covering that was a normal level it feels based on what we're seeing right now we think that those PCP and basically all those columns could be except for behavioral health could be it could have been suppressed for that comparison so I just think that's important to take with a green assault okay thank you I appreciate that if we could turn now to exhibit 8 I had a question on page 3 and a follow-up question to your answer on question 4 so question 4 asks you to detail your payment into the learning action network framework established by the federal government which tries to measure value-based care into different categories that they define and I just wanted to confirm my assumption that the 29% you have under all pair models built on fee-for-service architecture would that be the one care ACO program or would that include other programs that you have available your assumptions correct that 29% is one care and that's it okay and even though it's listed as upside gain sharing and my understanding that your contract has those up and downside risk no it's only it's level one so it's only it's only there's no downside risk being taken by one care at this point okay and why is that that would have to defer to our contracting team we would prefer to move them to a level 2 or a level 3 up and down side or capitation model but I don't know if there's any other questions that I can speak to the details of those negotiations I would have to defer to them are they here to answer my question no but we could I can definitely follow up with them as needed okay I would prefer that you do that and I and quite frankly I think this is going to be an area that the board is very interested in and I'll just speak for myself to say that it it is an area that it would be better if you could look at the value based care in the future so if you could please follow up in terms of the contract information related to moving the ACO program into downside risk or into a population based payment and I actually had several questions related to that but I think if if your contract team could get back to us in terms of sort of an expectation for how they would expect that contract negotiation to be furthered in the future that would be great my next question relates to question 5 which is the efforts to move individuals who are enrolled directly oh I'm sorry it's not question 5 it's question hold on question I believe it is so page 4 to 5 currently in prior years there were a number of efforts to ensure that individuals who did not receive subsidies were enrolled directly with the carrier in order to ensure that the silver loading did not adversely affect their premiums with the new ARCA subsidies that effort is being reversed to try and get people enrolled directly with Vermont Health Connect can you give us an update on those efforts and how many members are currently have been switched over to Vermont Health Connect out of a total individual enrollment as of June we've seen a reduction of directly enrolled members of about 220 members while our overall individual population has grown by about 80 members so our assumption is that those 220 members are still with us and they shifted away so it seems like our efforts are working and I know our contracting our communications team is working on a full rollout plan to try to ensure that policy holders are maximizing those ARCA subsidies and do you at how many total individuals subscribers you have directly enrolled I don't have a current that number I only had members we don't have actual subscribers that are currently I was 2,170 members directly enrolled members are currently in our population okay so out of I'm sorry out of how many 2,170 members at last count as of June 220 had switched over so we in this response we had quoted our direct enrolled members as of April that was 2,391 so we've seen 220 fewer members directly enrolled as of June to get to that 2,370 I got it thank you for clarifying yeah okay and how many members would you expect to shift I would hope all of them that are eligible for ARCA subsidies I don't think we've I don't think we've established a targeted number that's based on people you know policy holders being willing to change and adapt and reading their mail I don't know if our marketing team has come up with a figure but I don't have a figure again the hope would be that everybody would leverage and take advantage of those subsidies to help reduce their out of pocket expenses sure that would definitely be the hope I'm trying to establish the reality we can provide an update as needed I mean we only get monthly we won't have July figures for another few weeks so but to the extent that that's something that you guys request you know you can email feel free to email me or Chris Pontiff on my team and we can provide that as needed throughout the year thank you thank you I really appreciate that so I wanted to turn to your free file testimony which is exhibit 1816 excuse me exhibit 16 page 18 you can let me know when you're there it's hard to move things around in the binder there's a lot of paper yeah and this is where I think I'm a little bit crossed up because of all the changes that happened over the weekend so I'm gonna have to go electronic but I'll put it on the same screen so I'm reading the same off the same document or at least bring off the same screens okay is it it is the pre filed testimony the original pre filed testimony yeah okay date and question 31 is the question I'm interested in what concerns do you have about unmerging the individual and small group markets yes okay so in your free file testimony is it fair to say you express the concern of what might happen if the ARPA subsidies are not extended yes and the go ahead yeah I was just gonna say the concern is without the ARPA subsidies the reason why the rate increase is 17% in the small group market or in the individual market and 5% in the small group market I don't know I don't recall the exact figures but I believe it was in the ballpark of plus five minus five so probably about in the ballpark of a 10% swing if the state of Vermont didn't somehow find a way to continue offering those ARPA subsidies because right now that 17% increase that we're passing through a lot of that increase won't be experienced by policy holders in the individual market only people that are outside that range as well as you know some people are actually going to benefit from it potentially because of you know the increase levels throughout the throughout the FPL chain but if we were to if the ARPA subsidies go away we either need to re-merge the market or pass on those full increases policy holders in the individual market would experience it so somebody feels like would end up losing whether it be small small policy holders or individual policy holders but for the year itself this is sorry I was just going to say for the year itself I think it's great that we're able to you know I as Mr. Angolf gave kudos to me earlier for the vaccine assumption I think came I don't know I believe it came from each day but I thought it was a great recommendation for the year so okay great thank you I don't have any further questions okay move on to member Holmes do you have questions for Matt I do thank you hello Matt how are you doing good how are you I'm good thank you okay so this is a pretty complicated year I think we all can agree so some of my questions are probably going to be me trying to still untangle some of this but let me start with some smaller questions the well with respect to administrative costs an exhibit one on page 17 in the filing it was discussed MVP is making additional administrative investments in the state for 2022 and then in exhibits 10 and 9 it's further detailed that these investments would be quality improvement data analytics care management increasing care management staffing and capacity and I believe the total investment across the two markets is about $1.8 million is that right I think it was 1.2 and one of the markets and 0.6 and the other market these are additional investments that are admin okay and I guess my question to you is I would assume that MVP would make these investments unless it had expected some positive rate of return on these investments in terms of potentially lower costs and or higher quality so I'm wondering where in this filing is if it's in this filing at all is that net benefit in terms of lower cost or higher quality accounted for and if not in this year what is the expectation for lower costs in future years as a result of this investment is this something that we could go to executive session to discuss maybe confidential so I'd rather play it safe absolutely I have some executive session questions anyway so we'll just come back to that that's great okay also if you look at exhibit 17 which is the L&E report on page 15 I think it is let me just pull that up too there was this was about administrative costs that were assumed in the 2021 filing of 4375 and then budgeted actually budgeted later in the year was 3743 and so there was a big difference between what was assumed in the filing for 2021 and what actually later manifested in the budget for 2021 and there was a little discussion of this the timing of estimates of admin costs in the Q&A in exhibit 13 so I guess my question is is the delta between what's assumed in the admin costs and what's budgeted later in the year typically as large as what was described in you know the 43 down to the 37 that seems like a large delta between what's assumed and what's actually budgeted later in the year that is that is atypical is what I would say if you look at prior years which we provide and what I think we are just on one of the exhibits where we actually provide a five-year summary or a four-year summary of actuals and expected where we've generally been within a dollar plus or minus up or down from there what happened in 2021 is we have our budget is assumed our admin budget is developed one is based on estimated costs of running the business based on cost center owners at MVP meaning like the actuarial department would be a cost center the legal department is a cost center so on and so forth if there's changes made to that then that's just kind of if there's changes made to those assumptions then that can flow through into some of the components of the admin charges and then there's also a portion of it that just to think about the timeline which I think is what you're referencing we come up with kind of a global admin budget when we're setting our rates because we're setting them so early in the year and then from August through January is when we finalize the budget for the upcoming year so at the time when we set our rates we are making an assumption about what we on a high level what it will cost for on our business and the best approximation that we have is the most recent data that that we have which would be like the Supplement Healthcare Exhibit or the statutory filings from the prior year when we are setting 2021 rates we had 2019 data which indicated that we were going to need an adjustment a small adjustment to the current admin structure the 2020 change kind of came unexpectedly presumably due to changes made in that cost allocation model as well as certain different investment projects and how they would impact certain lines of business over others for 2022 there are specific investments that we're making which you mentioned in the last question that we already know will be undertaking and that's why we're building in those specific costs in 2022 okay can you point me to the exhibit where you have the assumed budget and actual for the past few years prior to 2021 so we don't actually so it is exhibit 10 is what I was thinking about on page 004 and this is just actuals but if we were to build in the expected amounts you would see that excluding 2020 we've been pretty close to our estimates okay that would be really helpful if somebody could follow up just with that with the expected relative to what the actuals were for that exhibit that would be helpful thank you my next question is kind of a new topic actually what premium impact if any did you include in your filings that would be due to the recent passage of the no surprises act which providers basically prohibits providers from out of network surprise billing as of January 1st 2022 was that considered at all in your filing for 2022? it was not it was not included I can't speak to the impact of surprise billing I know New York state has had that law a surprise billing law in effect for a few years when we when that did go into effect we didn't see any huge changes in general because there were some there were some amount but it was small, it was nominal to the whole pie the whole cost of care because for the most part we have an adequate network and a sufficient network so there generally isn't a ton of surprise billing taking place where members are being balanced okay well I just noticed that the congressional budget office estimates a reduction in commercial insurance premiums of between 0.5 and 1% when that you know act takes effect so we may have some follow up questions on that so this is this is related to what to do with COVID I think we're all obviously struggling with COVID in so many ways both physically and actuarially and so I want to just ask you a little bit probing I know Robin asked about this and the HCA attorney asked about this and Maureen did but I want to ask you a little bit about the symmetry and the consistency and some of your assumptions as you've very very clearly articulated in your you know in your testimony today and in your pre-file testimony that 2020 was a once in a lifetime extraordinary year in healthcare right and you know it's a year that you've chosen to use 2019 pre-COVID as the base period because 2020 was so anomalous it's not reflective of future years you know claims were uncharacteristically low due to COVID all of that I guess I just want to understand what's going to happen going forward my assumption would be that there would be symmetry in that assumption in that if 2021 as you've articulated already reflects pent up demand and some of this deferred services uncharacteristically high claims you would also exclude 2021 in future filings as a base year right from which to trend forward because you were talking a little bit about you know is this the new normal or is this pent up demand but I want to understand how you're going to disentangle the two because if you're omitting 2020 because it's anomalous I would think 2021 is also anomalous and how do you treat that going forward yeah I think it's all the interwoven parts of 2020 that makes 2020 so challenging in my opinion it's not it's the state of emergency with which I recognize there's still you know state of emergency in 2021 but prior off restrictions as well as COVID lab testing and then also importantly this is impacting risk adjustment to normalize our claims pent up demand the test the items that we're seeing I don't expect or we're seeing this pent up demand there's probably going to be some additional diagnoses that would impact risk adjustment but not to the same order of magnitude I would suspect COVID lab testing that's something that when we look at it we can isolate that figure out of our data and just remove it from the cost in 2021 so I think it's a cleaner adjustment using 2021 then it would be for 2020 just because I think there's a couple of items that don't flow directly into risk adjustment such as 2020 so they're in the pent up demand again we still haven't finalized with confidence because we haven't seen it taper off yet since the end of the first quarter but assuming that we do see this you know tapering off of those services I think those are more simple and clean and less interdependent adjustments to make to the claims so I'm less concerned about 2021 versus 2020 well I guess I would be concerned about using 2021 as a base year going forward for say 2023 is filing given all of the given all of the potential for pent up demand and deferred services even if you can carve out some of them so I guess I'm just going to put a footnote in that and that if you're going to treat 2020 as you know anomalous I think 2021 is potentially anomalous to going forward in rate filings I guess along those same lines you know you just mentioned that 2020 was anomalous because for example we had no prior authorizations right so I would think that for example your pharmacy trend which is largely in part driven by 2020's pharmacy experience right of 21% relative to the previous years that were under 5% growth in pharmacy again that seems anomalous potentially anomalous and yet you're using that as a part of your projection for pharmacy trend but we've already determined that 2020 is anomalous which is why you're starting with 2019 so to incorporate to say okay well we're going to use the pharmacy trend which is really high in 2020 to project forward our pharmacy trend we're not using any other medical claims in 2020 because it's anomalous seems inconsistent and I guess I would say part of you know my concern there is that yes there were no pre-authorizations in 2020 specialty drugs often have pre-authorizations so it would not be surprising to see an upward tick in pharmacy trend potentially in 2020 because there was no for example pre-authorization so how do you help me understand the usage of 2020 pharmacy trend in an anomalous year yeah it's those are your valid points it was surprising how much pharmacy was just not impacted by COVID the way that medical claims are impacted by COVID but we've had extensive conversations talking about what exactly why is this happening and there was a small component at why is this happening being why is pharmacy trending up at such a high rate there was a small component that we know is driven by the fact that there were a lot of 90 day scripts filled rather than 30 days so there could have been a little bit of increased utilization but that generally wasn't happening with those are more maintenance drugs more than they were specialty drugs our understanding was driving up the specialty drugs is because of these new indications which we may not necessarily ever be able to put back in place so once a member is actually utilizing a specialty drug it's hard to then say to that member we're not going to allow you to utilize that drug anymore because now we have a prior off back in place it may have improved their health and it's probably going to lead to such an immense member dissatisfaction that it it's probably not worth it from a member health and from a member satisfaction standpoint so if we're going forward we don't expect that specialty spike in utilization to actually come back down at some point but that would make no sense if new members are now afflicted with those ailments that require specialty drugs they would presumably be subject to prior authorizations and if those prior authorizations reduce some of the specialty drug utilization you would expect that spike to come down for new members experiencing those specialty drug related afflictions once prior author back in place yeah I mean our pharmacy trends for 2021 and 2022 are lower than they were in 2020 which I think has some I would have to follow up with our PBM to understand exactly how they're factoring in prior off and items like that but again the state of emergency is rolling into 2021 so those new members are utilizing those drugs it's going to be challenging to remove them from the data to remove their sorry to remove those new members from utilizing specialty drugs okay well I guess my concern is with the consistency and even with the TALA Health my concern about the TALA Health is that you're using the third and fourth quarter experience to project claims going forward around TALA Health and isn't it possible that this too might be anomalous that there is still some pent up demand there still is some in-person fear of in-person visits or fear of lingering fear of in-person visits so I guess my overarching concern and I'll just articulate it is that you know if 2020 is deemed too anomalous to use for claims experience why are we relying so heavily on the critical trend for 2020 and why are we using the second half of 2020 to project forward to TALA Health when it's clearly an anomalous year so I'll just articulate that in your pre-filed testimony you exhibit 16 page 9 you discuss marketplace primary care improvement program as the main vehicle through which MVP is promoting affordability quality and access in primary care sorry page 9 it's your original pre-filed testimony exhibit 16 are we there sorry on all these documents okay I'm there okay perfect I just want to I was surprised you discussed that providers are eligible for some financial incentives if their performance on a couple of cancer screenings and diabetic exams exceed the 50th percentile but in 2020 only three providers in Vermont actually received that payment again 2020 was an anomalous year so perhaps it's because there was fewer screenings and fewer in-person visits and all of that happening I'm wondering what did you do to have this program in 2019 and if you remember this but I'm just curious three questions I really know number if the target is the 50th percentile and actually my question two questions one is is the 50th percentile across you know both your New York and your Vermont provider network is it just Vermont's provider network and were you surprised by that number three and is that anomalous to previous years in terms of the quality of primary care delivery in Vermont so I believe in last year's pre-filed testimony we had similar data our clinical team provided that information and I was surprised by the figure that it was it seemed low but it wasn't that low if I recall I just I have a mental flag in my mind of it's lower than I would expect so in terms of you know outreach I know our quality team is you know they perform outreach and try to provide provider education to improve upon those quality metrics because as you can improve quality as you know I'm sure you're aware that can help reduce downstream costs right it reduces unintended low value care improves member experience improves population health you know so we provide these incentives in hopes of actually providing you know that the amount that we're paying out in incentives is more than offset by reductions in costs but if I do recall from prior years the number has been low in the state of Vermont so that must mean the 50th percentile is set you know jointly with the New York providers right so Vermont providers seemingly are performing lower than New York I apologize I believe it's based on national published data okay got it General Counsel Barber could I begin briefly go ahead Gary this witness has been answering questions for two hours since the last break I just like to check in with him see if he like a break and just what your plan was to break I don't want to break obviously in the middle of the board members questioning but just to get a sort of a final yeah I was hoping we could get through board member questions take a break and then it sounded like there was some questions that may be appropriate for an executive session so break for lunch come back do that and I don't know I wasn't certain how to do the executive session in relation to redirect so if we have a preference on that but I was hoping to get through the board member questions before we take a lunch break if we need to take a short 10 minute break here happy to do that I wonder if even a five minute break now just in case the obvious one needs a short break and then come back and then we won't be rushed in any way okay I I'm going to admit that I don't remember where we broke whether it was a question from member Holmes or an answer from Mr. Lombard yeah I think I had my question answered I did have a few more but not very many so hopefully we'll be able to at least I have a couple for executive session but only a few more for this part of the hearing okay this with the next question is around case management in your pre-file testimony I think it's around page 11 you describe the case management program my first question is what is the risk level for case manager how does that determine it depends on the condition or the condition or the diagnoses that a member has risk high risk patients it may not I would say that's relative you know I think it could be it's members with condition chronic conditions in general or a specific one-time event that needs to be managed to help ensure that they're getting adequate care high quality care okay in that in your testimony there you state that the case manager is again on page 11 will ensure members have access to information to support the selection of providers and facilities that will move members into systems in which standards of care are utilized effectively and will provide cost effective outcomes so my question is how does your team or how does the MVP team determine which providers and which facilities are utilizing care cost effectively and which are not how are they determining you know basically high value care and how are they moving patients away from low value care and that sounds like they're directing care to high places right utilizing care effectively and providing cost effective outcomes so how are they doing that so the selection of the exact location is is not something that I could I could answer essentially there you know my understanding of the program is it's utilizing it's member outreach to inform members of basically ensure that they're adhering to their medications and doing their follow-up visits as well as you know again it's it goes back to managing your care and having high quality care is going to help you know lead to that tripling of health care but the specifics of the program like how are they choosing the exact location that's something that would have to defer to the case management team yeah I mean these are all going to be related questions to this because I'm really trying to understand how MVP is directing care to low cost high quality providers and so you know your answer to the question touched on that in the MVP supplemental health care exhibit in their expense report MVP outlines quality improvement expenses which include physician profiling performance review chart review there's discussion about medical policies and utilization management and I'm trying to understand on the ground how MVP is directing medications towards that high quality low cost care and I'll just add another kind of subset to this question in exhibit 8 page 4 MVP was asked a question about low value care right which largely is defined by unnecessary and harmful and costly care okay and in that response the first part of the response was addressing low value care requires education to members that more care to good care so maybe to your clinical and case management team I would love to know what steps they're taking to actually educate members about that the second part of that response is a close partnering with providers who champion a focus on low value care you know low value care reduction is essential so my question there is how do you identify those providers right what criteria is used by MVP to identify those providers that are going to deliver high value care low cost high quality care and your third part of the answer there is or the third part of that answer there is that you need downside risk alternative payments and capitation is needed to reduce low value care and again if you look back to Robin's question and that the delineation of your contracts none of them have downside risk none of them have capitation in Vermont so I'm trying to understand and maybe this can just be a big broad question for your clinical team but in all of these areas there's physician profiling happening there's a recognition that education to members is important different risk contracts are important partnering with providers who identify as low cost high quality care but I'm not sure how you're actually executing that on the ground how you're identifying providers and providers you know what steps is MVP taking to exclude providers who underperform on cost and quality are they moved out of the network what if they're in a hospital does that you know provider no longer be included in the network so a lot of questions were raised for me from some of these answers and so I'm just going to bucket them all together and perhaps somebody from your clinical care team can try and address that bucket of questions and I can provide a little bit of background that I know we've done our New York population we're actually starting to do this with our Vermont population is understand costs by E.T.G. episode treatment groups so what we're doing is trying to compare across our network how are what is the overall cost of managing a specific episode of care by provider A versus provider B versus the block of business average that's then trying that's then being balanced against quality so we have quality metrics in place that we're also measuring so over time you know that is kind of the framework that we're using to evaluate how do we address our network and how do we steer our members on a high level the actual detailed directing of the members is outside of my area of expertise okay great thank you I look forward to that I think the rest of my questions Mike are for executive session potentially okay why don't we talk about that after member Pelham and the chairman ask their questions because I need to understand a little bit more just the subject matter and how it might fit within the statute so go over to board member Pelham do you have questions for Mr. Lombardo I do have a couple of kind of brief follow-up questions again kind of being near the end of the line it's always helpful as you have some very talented people asking questions before me so my member Holmes just read from answers in exhibit 8 having to do with MVP MVP's approach to value-based care and so when I read that same language that she quoted I began capitation was mentioned quite often and on the previous page you know to in the exhibit the 29% caught my eye because it was still based on fee for service and there wasn't any kind of a capitation explicit reference there and from my view capitation is the most powerful tool that we are one of the more powerful tools that we have in the foundation of healthcare reform in Vermont because it's foundational to induce providers to be innovative and creative so I went looking for where are we now this is narrative aspirational narrative but where are we now and so my question is I kind of in this regard a valid kind of calculation so I went back to the index rate development for either the small group or the individual and so that is what I'm about now is the index rate for small group which is in exhibit 2 on page 44 and we've been here once before today already yep okay so my I mean I understand that this is an index rate I understand that it's you know it's based on 2019 data but I'm looking for a starting point that we can begin to measure in this process the kinds of questions that Jess was just asking you so I look at the line 13 where it says experience period capitation and non fee-for-service medical costs so here's where capitation would be and that was $10.09 of the developing experience here index rate and the numerator that would be for the experience the 300 $387.90 and so that is for the small group compliant that's a 2.6 percent factor and if we went to the the same page the ACA compliant individual group that would be a 2.9 percent factor and so I look at numbers like that and A my question is are those reasonable measures of the investment in capitated claims payment by MVP and if so where would you expect a reasonable level to be that was significant and was influencing the market so first that is a combination of claims that aren't processed through our claims operating system plus capitation amounts and we do break out those expected costs so it's less than that amount is capitation and I think capitation is actually a pretty low number it's essentially I would say we do make a capitated payment PCP incentive payment to our providers in one care outside of that it's all just non fee for service claim expense items meaning it's a claim or it's a surcharge like the state of Vermont has a paid claim surcharge that's not necessarily processed in our claims operating system so we add it on in this line item so I would say capitation in general is actually an even lower percentage significantly lower percentage I can say that I know that our staff did spend some time with the URRT I call them URTS do but URRT and found that for MVP the calculation for and the individual was 2.15% and for small group 2.31% but because this document wasn't in the record that's why I went to this index rate to try to get my hands around the number that's meaningful and I either way you do it it doesn't seem meaningful to me and here we are three and four years into our health care reform effort trying to change the system and on the ground it's just would say we're dealing in percentages that are pretty minuscule I would agree that there you know it's in the range of 1 to 2% somewhere in that range that's probably not going to have a huge influence overall MVP is fully committed to moving towards those kind of models because we believe that that will help improve population health and improve cost efficiencies and increase member satisfaction because then doctors can provide care you know rather than you know we can they can provide care rather than fellow charts and do things like that right for fee for service and that's what we're calling at the end of the day though there has to be it's a two sided conversation that's conversation I'm not really part I don't participate in what my team works on is the actuarial side they tell us the terms of the agreement and then we help we help on the back end once the terms of the agreement are established so I just think you know those conversations it's a it's a two maybe both parties are willing to adopt a model and come to common terms or there has to be a mandate in place so those are the two items I think can you know without having somebody say you must do this or else you're going to face some sort of penalty you have to come to common terms those are agreements and conversations that I'm not really I participate in every once in a while but I'm not actually sitting at the table helping move those conversations along and I do have it written down from board member lunch did did say that she's looking for us to bring somebody with us next year that could speak to that kind of information and I will bring that back to our executive team well one of the things I would suggest is that in last year's budget order for the ACO we had a condition 15 put into that that asked them to provide us targets for you know for capitation etc and there's a draft memo I know that is in play you know as we speak and it's looking at numbers in 2023 in you know 25 30% and which begin to get to a critical mass that might have some influence so I'm just and I fully agree with you in terms of this being a carrier issue and a provider issue and you know we as a board kind of operate on both sides of that and where we can you know come to come to be a force to kind of bring these sides together is something I think we're all interested in the other question I had again and it's been touched upon but and it does go back again to exhibit eight and we don't have to go there is the billing question that with from my health connect billing question and I didn't know what the number was in terms of the marginal cost to MVP in this arrangement but I just want to understand the arrangement a bit more this these are functions that Diva performed and now the carriers have agreed to assume the work that Diva did your estimate is I think as I understood it was that it's a cost in this rate hearing of about $300,000 that's the marginal cost incremental cost from the filing and I'm wondering if you have any idea how much Diva saved relative to the duties that you folks picked up I am not aware of how of what Diva's costs were for these programs but I guess my concern and I didn't have I should have had it but I missed it I didn't have a full focus on the number but to me at any level this is cost shift you know we all bad amount the cost shift but this is cost this is taking a cost that a state agency had and paid for with both federal and state funds and shifting it on to rate payers and premiums and I just think whether it's large or small it's just a bad practice and something that I'm concerned about in the grand scale but also more you know at the smaller scale and just one other kind of contextual question here are the legislature in the budget this year passed legislation to take a relook at the benchmark plan which is the foundation for the plans that we're discussing here today and there is a report back to department of financial regulation on January 15 by January 15 of 2022 and I'm just wondering does MPP have an approach to this the specific language in the bill says assess whether the benchmark plan is appropriately aligned with Vermont's health care reform goals regarding the population health and prevention so that's one broad mandate and then it has five or six additional benefits that they would like to have considered as part of the benchmark plan and I'm just wondering how far along your thinking might be in terms of engaging in this process Yeah, I think we're waiting I know there was some early conversations a month or two ago that I believe the board and the board had participated and I think it was actually a call and they joined but since then if I recall there's a series of meetings that have just recently been set up and we're waiting to listen to the Vermont regulators to we're thinking about things right now and if we think that there's actually any significant modifications that we can make and we plan to participate in those conversations I know our product design team is going to be fully engaged in them and we'll have some more direct-in-affairs the actual real team will come in and help them out in supplement and we have to provide rate analyses and rate estimate impacts so we will be participating at this point though it can't provide much more detail on the current status and those are my questions thank you Thank you you're on mute is that better sorry about that my neighbor has been weed-whacking or something so I've been on mute my apologies as Tom said when you go last most of your questions have been answered but I want to go back to a few of the previous questions and maybe ask them in a little bit different way starting with how you manage your prescription spend and you talked about using CVS and you talked about your mid-market checks and so forth and that you thought that you were getting a good deal Maureen asked you when you thought the next RFP would be and you didn't know just curious if you know when the last RFP was a specific date I don't recall a few years ago though a few being a little bit wide range if the specific date I don't recall but I know that I helped participate in some of those conversations and analyze the financial impact okay on that same topic you're using CVS care mark what protections are in your contract with them to make sure that their pharmacies aren't advantaged over other pharmacies? That would have to be something that I would have to look into the contract terms and work with the pharmacy team to uncover that I think that's one of those in the details contract pieces of information how they're structuring their discounts if there is a difference in structure discount by pharmacy or if it's just a broad discount that's applied across all pharmacies in its universal. It's just hard not to focus on that pharmacy trend when it just really jumps right out at you next line of questioning and again you were questioned earlier about L and E's talking about 800 new members I think maybe it was member Holmes questioned you on your concern about the elasticity of your numbers given the changes in the pricing and we've seen that in 2016 you had 10% of the market and now you're up to 50% when I started in 2017 you had a little bit over 10,000 members now you have over 37,000 members just you've seen the different filings that have been put in between you and your competitor do you have concerns that I know you said that you and I appreciate that you feel that if you provide a good quality service that for monitors probably may not flee but they left your predecessor when they came to you and I'm just trying to you've got L and E with the 800 new members there's concern with your higher pricing if you're losing memberships I mean what are your thoughts on this and could it drive up your numbers? Yeah those are fair and very good questions I mean obviously there's some level of concern to gain 27,000 members in a matter of a few years is something that we've been proud of we don't want to watch those members leave us and walk out the door how it would impact administrative costs I think it's too early to come up with any sort of adjustments or speculate on that impact you know we have been having conversations with our sales team but everything is based on preliminary proposed rates so again we're trying to be patient and wait till the final approved rates to see how we stack up to really try to pinpoint what we think is going to happen in 2022 but you know when we set our rates as long as risk adjustment is working to some extent for the largely working then we're normalizing our populations then we're competing on how well are we managing our costs whether that's through admin or care management and case management or unit cost contracting we are though again your point is valid that we are how concerned are we I wouldn't say incredibly concerned because I think we're reasonably aligned based on proposed rates and we've looked at what the L&E recommendations are as well as the impact on the hospital budgets and we think that we're going to be reasonably aligned we're optimistic that we'll be somewhere in the same range of membership going forward okay the question of pent up demand has been beat pretty hard I guess I'll just follow up on it one more time and just to ask you if you've done any surveys of providers to try to get a handle on when the pent up demand will have been met so obviously people weren't going in for their colonoscopies and mammographies and all that kind of stuff but what type of backlog are you hearing about from providers and when should that expect to end I haven't participated in conversations with providers I don't know if our clinical team or a contracting team has been in those conversations that would be something I'd have to ask them if they've had those conversations we are monitoring the actual rail team every month when our data when we get our monthly refresh of our claims we know the services the types of services that are hitting us that we're seeing the increases and one of the first things that we do once our claims come in is we loop through our data and we analyze how are these costs changing as time is going on March April and May were extraordinarily high in those handful buckets we are seeing a little bit of a dip in June but it's also as we talked about earlier the IBNR factor on the first month is like a 2.8 factor is what we had earlier so it's almost triple whatever we've actually paid so it's hard to actually analyze how June is going to look again every month this is something that similar to Board Member Lunge asking about direct enrolled members to the extent that we can provide any feedback to you guys throughout the year we'd be happy to do that right now though the data that we have is showing that it's not continuing to rise because what we first saw on March was oh no it's spiking up like what is it was the first thing because at first you just saw the total dollar amount spiked up then when we started drilling into it we said okay well hopefully this is just pent up demand of services but then it became a question of is it going to continue to rise or is March and April are those going to be the high points I think it's too early to call right now but we're hoping and what the most recent data is showing is that there could be a leveling off or a slight decline but it also could be this new normal which is the thing that we actually fear so you know we're more than happy to provide some update information as the year goes on if that's something that you guys will be helpful for you guys I think it would be good to hear from the providers and see what their their belief is and what their backlog is but my next question given that the premium tax credits or subsidies are tied to that second low-cost silver plan which happens to be your product have you had internal conversations about that and how it will affect things yeah I mean we've taken a look at where we will be with our proposed rates and I think we would still have the second-loss cost silver plan and just try to model out we don't know exactly where the premium which premium level everybody is at right now but what we do what we do have an understanding of is how is that going to change you know how are members actually going to be impacted based on various FPLs so I don't have the spreadsheet in front of me but that is something that wants to prove rates are out or even proposed rates yeah we do take a look at that to try to understand how members being subsidies are going to be impacted so there's been a lot of conversation today about whether you benefited from the pandemic we had a conversation about your payout being less than 90% but then you talked about you're seeing this larger more current payout on January 7th Phil Scott here in Vermont announced that he was charging the department of financial regulation to do an analysis to see whether or not a rebate would be in order for insurance customers and of course we at the board thought that we would receive some information on that probably in a 75 to 120 day window but we didn't get that until last week and in that report have you seen that report that DFR issued they DFR shared with us a report I believe last Thursday or last Wednesday but there were some information missing I believe they just removed some of the carrier specific data from the other carriers but they did share with us the report for MVP to understand if we want to redact anything which so I did read through that MVP specific portion of the report were you involved with conversations with DFR's actuary Oliver Wyman in the preparation of that report we've supplied data to to prepare to help prepare the report we didn't participate at all in the actual preparation obviously but yeah we did supply the data to the DFR actuaries so in that report and it must have come from data that you supplied to their consultant there's mention of a 24 million dollar underwriting problem and I'm curious does that just include Vermont I would have to pull up the report itself to see where that where that calculation is coming from we'll go to it right now do you recall and the pages may be thrown off because of I don't recall unfortunately because of the timing of that report it was a quick read yeah okay yeah I don't recall seeing that 24 in 20 and it says in 20 underwriting loss I am not specifically seeing that figure they did quote a projected loss for 2021 but we only provided limited information to them for 2021 we've provided and they're forecasting the report that I'm seeing is showing that their forecasted loss is a 21.7 million dollar loss if I'm reading this correctly I'm trying to skim it at the same time as well looking at section 4.1 okay under I'm glad you pointed out that section because that's a follow up question they had with you as well because it's talking about the risk adjustment payment and you talked about a little bit of that earlier but we saw that Luke your competitor talked about the fact that they have a healthier population now so I guess one would assume since that you're dealing with this pool of Vermonters if they have a healthier population that MVP must have a less healthy population and if that's the case will you get a larger risk adjustment payment yeah I don't so I guess I don't understand how they derive that I guess as a percentage so when we initially started growing market share we saw our percentage payment into the risk adjustment program start spiking up in 2020 that figure came down a little bit so that may be what they're implying is that you know we I would expect that we're still going to have a significant payers I think overall we have if you were just to take our population versus their population we are going to be payers into risk adjustment but the new members that may have come into the market for each carrier it's flattening out a little bit but not to the extent that it's going to swing everything as much as one would you know as maybe was led on to based on our payment in 2020 it's a little bit of a more favorable population a little bit closer to the market wide average but it's not materially we're still we're still significant payers who still paid over 20 million into risk adjustment okay so those are the questions I had hearing officer thank you okay Mr. Angolf Mr. I think now would probably be a good time to break and we can come back from the break and expect to go into an executive session of followed by redirect would be my expectation does that sound agreeable fine with that that's fine the question is how long of a break should we take an hour or half an hour and I think we have enough time to get through everything so whereas we could take an hour but I'm happy I would advocate for the shorter time frame go shorter if folks want to go shorter sounds good okay I would like to understand a little bit better the questioning and answering without disclosing any confidential information the kind of nature of what we would be discussing in an executive session so I understood Jessica you had some questions and I believe I heard someone else mentioned that they might have some questions about confidential materials Jess could you help me understand a little bit well one of my questions which I asked Mr. Lombardo was around the administrative investments I guess that's for his reasons preferred to be an executive session my own questions were around hospital specific reimbursements and some of the confidential documents that we received okay was I mistaken that there was another board member who might have question about confidential materials I think I asked about something that I wasn't sure it would be confidential or not and it was not which is the telehealth exhibit okay so the hospital specific reimbursement information that we received has been determined to be exempt from public inspection and copying under the public records act and there is a exemption in the open meetings act allowing you to go into executive session to discuss that regarding the administrative investments in Vermont I think I need a little bit more explanation of how that might fit into the executive session criteria so Gary if you want to talk with Matt about that during the break and help me understand that when we return that's fine thank you so to be clear Mike are we coming back to this setting so that you can have that conversation and then we'll leave this setting and go to the executive session setting we need to we need to have a discussion and vote in an open setting before we someone makes a motion to go into executive session so yeah I would expect we would come back have a brief conversation and then go directly into the executive session could I ask a question Microsoft teams question then are you then invite us into the other section and we click on that or do we need to go out to our calendar you would need to click on the invite to the executive session that was distributed earlier so we'd all leave this meeting it would continue to run and then we would all you know once the executive session is closed come back and rejoin the public session thank you and like I said we'll have a brief discussion of the the bases there need to be some votes and so I don't we all break at this point and come back at 135