Good morning. My name is Owen Foster. I'd like to call to order the Green Mountain Care Board's board meeting of November 9th, 2022. We're here today for hearing on Accountable Care Organization One Care Vermont's fiscal year 23 budget. First, I'll turn it to Ms. Barrett for the Executive Director's Report. Thank you, Chair Foster. I want to just remind folks that there are several ongoing public comments, and I'd refer you to our website. There's an open public comment periods. Please check the Green Mountain Care Board website under public comment. There you'll have the you'll see those several open public comment periods and just be aware there are dates that comments should be submitted in order for those comments to be considered by the staff in their recommendations as well as by the board in their decisions. I also want to announce that on November 7th, 2022, the board issued its decision and order approving modifications to the MVP Health Plan 2023 large group HMO rate filing. The decision and order is posted on the Green Mountain Care Board website under what's new and also on the filing page on our rate review website.  Thank you. I'd like to take up the minutes from November 2nd, 2022. Is there a motion to approve the minutes from November 2nd? I move approval. Second. Is there any board discussion? Those in favor, please say aye. Aye. Aye. Aye. The vote is unanimous and the minutes are approved. I'd like to turn it over briefly to Marisa Melamed. Good morning, Mr. Chair and members of the board and the public. I'm going to give a quick introduction before we turn it over to OneCare for the hearing. Can everyone see the slides? Okay. Good morning, everyone. Are the slides showing up okay? Yes. So I just want to give a quick introduction in Oriental from the process here. I'm not going to go through all the details on each of these slides because we've been through them before, most recently on October 12th. This is the budget hearing for OneCare Vermont ACO. And as a reminder, all ACOs operating in Vermont are subject to budget review. There's a threshold of 10,000 lives that defines the scope of the review. Also, that OneCare is a multi-payer ACO with contracts with Medicare, Medicaid and commercial lives. And this budget hearing occurs annually in the fall. We revisit the budget in the spring and we have monitoring that goes on year-round on budget activities. The ACO oversight process is governed by the standards of review on this slide, which again we've been through before, but they're available here for your reference, the statute and the rule and specific criteria under the rule that the Board must consider. Here's the timeline for the process. So we've made it to November 9th. And that is the hearing today. The next step in the process is we are revisiting the recommendations for the other ACO under review next week on the 16th. And we'll be back to discuss OneCare Vermont on November, sorry, December 7th with staff analysis and preliminary recommendations. The budget needs to be voted on by the end of the year. At the moment, we are expecting a potential vote to be December 21st. The agenda for today, this is the staff introduction. We have time for the OneCare budget presentation. There will be some staff questions, break for lunch, which will be at the discretion of the chair, board questions. We can move to executive session if that were to be necessary to discuss confidential information. There's time for the healthcare advocate questions and public comment. And the timing will be sort of set by the board chair as we go, but roughly it will be broken up into two components prior to lunch and after lunch. And at the end of this slide deck, which is posted online, there are some reference slides which people on the call might find helpful for their reference. All the materials are posted online that we'll be referring to. And then the criteria under 18VSA 9382 that the board must consider. So you should be able to find all those materials online. And if speakers could try to, to the best of their ability, you know, make reference to where information can be found so that people can follow along. And that's it. I'll turn it back to you, Mr. Chair. Thank you. Thank you very much. Participants today have all blocked their full day so this large, complex budget can be adequately understood and the board can make informed decisions in fulfilling its obligations to review and determine whether to approve one care Vermont's budget. Vermonters, myself included, want to see one care succeed in implementing programs that reform healthcare in ways that lower costs improve equity, access and quality of care. Given the immense pressures on our healthcare system, the acute healthcare affordability challenges we face, it's critical that one chair achieve its mission and improve healthcare for Vermonters and stabilize healthcare costs. Vermonters have heavily supported one care since its inception. Since 2018, one care has had a full accountability budget of over $5 billion. And with this year's budget, nearly $6.5 billion. One care has had an entity-level gap budget of over $100 million since 2018. And with this year's budget is approaching $130 million. And one care's operating budget has surpassed $71 million and will be approximately $87 million if this year's budget is approved. Vermonters, either through taxpayer-funded healthcare groups, out-of-pocket expenses, co-pays or insurance have borne the bulk of those staggering numbers. And for that, they deserve results. Vermonters need to know what they're getting for their money, and it's this board's job to ask those questions. If one care is meeting its mission, Vermonters should know it and should continue to invest and support in it. If one care is not, we all need to know that, understand why, and consider any such failings in assessing its budgetary asks. I read this year's one care submissions, the slide presentation, and the transcript from last year's hearing. To my eye, the fiscal year 2022 presentation by one care was not particularly well-focused. It was long on process and light on demonstrable results. As I understand it, the board has made one care aware of its keen interest in understanding whether and by what quantum one care is impacting cost, access, and quality. So I ask one care to please concentrate your remarks on objectively showing the impact one care has had, not through one-off anecdotes, but quantifiable metrics and analysis that tie back to one care's work. I'm anticipating today that it will be significant staff, board, and healthcare advocate questions, and potentially much public comment. Accordingly, and in light of our efforts to focus your remarks on what we need to evaluate in connection with this year's budget, please keep your presentation to under 60 minutes, and 45 minutes would be even better. If there's material that we need to get to that we weren't able to, we can take it up again after public comment. We're scheduled to go to 430, but if we need to, I have no problem staying later today. As I'm sure you all can understand, you're entrusted with enormous sums of our modern's money, and there's huge responsibility that comes with that. You're under oath. Your responses should directly answer the questions, and you should strive for candor. Obfuscation or misleading responses are detrimental to this board's review in the process, and I'm sure you all recognize that and will avoid it. And with that, I'll turn it over to Mr. McCracken to square in the one care folks, and thank you one care for being here and providing us this information. Thank you, Mr. Chair. This is Russell McCracken. I'm a staff attorney with the board. From the one care team, could you just confirm who is going to be speaking today? Yes, so Vicki Loner, CEO, one care Vermont, Sarah Berry, COO, one care Vermont, Tom Borey, vice president of ACO finances, and Kerry Wolfman, CMO, one care Vermont. Great. Thanks very much. If you had raised your right hand. Do you solemnly swear that the evidence you shall give relative to the cause now under consideration shall be the whole truth and nothing but the truth? Shall I help you, God? I do. Yes. Great. Thanks very much. You're under oath, and I will turn it back to you, Mr. Chair, or I can turn it directly to the one care team to start. Yeah, please. The one care team can go ahead and thank you guys for the work in putting together your presentation for us today. Great. Thank you, Chair Foster, and thank you other members of the Vermont Care Board. Amy, could you put up the slides for us, please? Next slide, Amy. I'm going to kick off the presentation. My portion of the presentation is going to be very brief, highlighting some of one care successes and accomplishments over the year. And then my team will do a deeper dive as we go further into the presentation. At a very high level, the 2023 budget looks to advance our mission by focusing on our core capabilities that were developed as part of our strategic planning process a few years back. That strategic planning was accomplished, and we are looking to have a refresh on our strategic plan and priorities in 2023 for a 2024 start. I want to start off by talking directly about the value this budget before you presents to Vermont healthcare providers. And also on the next slide, I'll talk a little bit more about how it looks to deep an engagement in value-based care and moving away from a fee-for-service construct that we've been with for decades now. In terms of value to providers, you'll see throughout this presentation progressively increasing provider network accountability that looks to improve the quality in outcomes while reducing the administrative burden on our healthcare provider delivery system. I want to be very clear that these aren't year-over-year changes that you'll see. Population health efforts take time to be able to measure such outcomes. But I believe that over the years that one care has been operating, we have demonstrated significant outcomes and value to both healthcare providers and Vermonters. This year alone, we are infusing over $30 million directly to healthcare providers to support population health efforts such as care coordination and quality improvement with a big focus on primary care. And later on in the presentation, you'll see that the preponderance of these investments go direct to primary care that they wouldn't otherwise have available if not for one care of Vermont. Another big focus as an ACO is on engaging the full continuum of care. So as you look at our network, one care of Vermont is more than hospitals. It's more than primary care physicians. It represents a full continuum of healthcare providers working together as a system. Through these efforts, we've been able to advance care coordination and we've been able to leverage federal dollars for blueprint and SAASH care coordination programs that otherwise would not be available if not for one care of Vermont's existence. I also want to talk later on about many of the innovations in payment and healthcare delivery reform direct to primary care such as our comprehensive primary care program that has more than tripled in numbers since 2018. Next slide Amy. All of these operational and investments that I've talked about on the previous slide has really resulted in a deepening engagement into value-based care. You'll see throughout the presentation that we are returning to our pre-pandemic levels of risk and rewards through all of our programs to the sum of 36.5 million dollars that will be available as risk or could be a reward opportunity for the providers delivering the healthcare to Vermonters. We have 1.4 billion dollars of eligible healthcare costs and value-based care arrangements anticipated. Remember this is always a forecast because we don't have final numbers from payers until the beginning of next year collectively. We have maintained a solid statewide network of over 5,000 healthcare providers. It's over 170 distinct organizations that participate in one care of Vermont and over 80 percent using Green Mountain Care Board data of eligible primary care in Vermont. We've had significant growth in programs such as Medicare and the Comprehensive Payment Reform program over the years even despite a changing landscape and our Medicare advantage. If you compare us nationally in terms of overall cost and economies of scale, our admin rate is significantly below other ACOs at about 1.1 percent of total cost of care compared to the national average which is about 2 percent and you'll see a reference point for that number at the bottom of this slide. Next slide, Amy. For those of you who have not heard our budget presentations in the past, 1 Care of Vermont through a strategic planning process really looked at what should our core capabilities be. I think a lot of individuals have different perceptions of what 1 Care of Vermont should or should not do and we as a board and a leadership team made a decision on what those core capabilities would be and so all of our efforts and activities moving forward follow through our core capabilities that were developed as part of our strategic plan. So they're listed here, Network Performance Management, Data and Analytics and Payment Reform. Next slide, Amy. I'm going to highlight in each of the categories the work and activities that 1 Care Vermont and its network of participating healthcare providers have done over the past year in these particular categories. Network Performance, when you think of Network Performance, what you should view in your mind is this is our contracting efforts to really assemble the full continuum of care providers and our population health model and investments and remember our population health model investments and activities are carried out by the healthcare providers that take care of you every day. So they're not done at 1 Care Vermont, they're directly supported by the participating providers in 1 Care, which are your healthcare providers. In the care model space, which is our population health model, Dr. Wolfman will talk in detail about the good work that's been done through leadership committees and our boards to look at our population health governance structure and really restructure and revitalize that committee and boards to maximize statewide voice on both ongoing programs as well as overall strategy so that people have the ability that our internet work to influence from the ground up. This group of clinicians has worked really hard over the past year to look at our population health model and to say how can we push that model to further deepen engagement and accountability in the efforts through 1 Care. And at the same time, how do we simplify it so it's easily understandable to the clinicians that are participating in the programs and to the patients that are being served by these clinicians and these extra activities. In terms of our network contracting, we hold over 5,000 providers in our network. That's a statewide network across multiple payers. We're a very diverse network of provider. We have maintained and this shouldn't be understated. 100% retention of that network going into 2023. We have 14 hospitals, 82% of primary care and continued growth in programs like Medicare and Comprehensive Primary Care Reform Program. We've maintained about the same level plus or minus of attributed lives in the program since 2022 budget year. And this is really quite amazing considering the changes and the payer landscape that we've been able to maintain this network. In terms of outcomes, Sarah Berry, our CEO will go into more detail about what we're seeing in terms of benchmarking across other like ACOs. It shouldn't be a surprise that we are very low cost Medicare ACO and compared to national cohorts. In 2021, we continue to meet and beat the benchmarks that are set by the Medicare payer in order to be able to send back shared savings direct to our network providers. None of this funding is kept within one care of Vermont. It goes directly out to those providers delivering care and services. With 2.5 of that, savings going direct to primary care practitioners through our programs of that 5.5. So just let me be clear, primary care receives more than 2.5 but they're receiving 2.5 of the 5.5 million. When looking at our clinical focus areas, we have exceeded most clinical measurements and in the one area where we have not, we are working directly with healthcare providers who can influence these measures to look at opportunities for improvement. Next slide please. Data and analytics is our next core capability. Our team have been working directly with our participants, our boards, and our committees to understand how we can make improvements in our reporting and our engagement with our network around data and analytics. I'm pleased to report in terms of reporting and resources. In this year, we had developed a new suite of primary care quality and health disparity report cards for our statewide network. We had instituted a benchmarking tool to identify strengths and opportunities for Medicare specifically and we are in the process of working with our sole member to transition our current analytics platform to an enhanced platform that would enable us as a system to be able to have more standardized reports that are less labor intensive for the unique network that OneCare Vermont is. In addition to reporting, we're also working actively with our network of providers to talk through how we can really work with them to point out areas of opportunity and how we can be supportive in giving them data and analytics to be able to further improvement. This has resulted in what's called a health service area accountability reporting structure where our teams work with local communities to point out insights and work with them on how to make improvements in that area. We've had really nice engagement. Dr. Wolfman will talk about that later and our hospitals who as a reminder bear the preponderance of financial risk in these programs have really engaged in our using additional tools and self-service analytics to be able to identify opportunities. Next slide, Amy. In terms of payment reform, fixed payment is always a big topic of ours. We've been working actively with the Department of Vermont Health Access or the state Medicaid department to bring about new fixed payments for both the ambulatory surgery center as well as test sites for hospitals that will commence later on in 2023. As you know, as a signatory to the all-payer model, Medicare will not be advancing their model. At least that's what they're highlighting to us. They will continue to reconcile to fee for services payments up until a new all-payer model may be reached as late as 2025. We have been working actively and aggressively with payers and based on the current negotiations we do not anticipate that they will move forward in any sort of fixed payments next year. Next slide, Amy. Comprehensive payment reform program. This is a program that was developed in 2018 primarily to support our independent primary care practitioners. We've moved from six sites. That's not six tins but six actual sites in 2018 to 19 sites as of 2023. When verbally surveyed, the greatest satisfaction in this program has been with the stable fixed payments. They receive a predictable per member per month payment across all payers plus an enhanced incentive for advanced primary care services such as mental health. If you look at the data in aggregate in 2022, practices earned on average, and this is an average 23 percent more as compared to if they were just to be in a fee for service system, enabling them to really enhance the services that they offer to their patients. We've been working directly with these payment reform practices to say how can we do better together? What are further enhancements that could be made in the program and how do we look to truly evaluate whether or not people are better off because of this program? That's ongoing work. I believe that you heard through a primary care panel a couple weeks ago. The value that primary care providers feel that this program brings and that this is true payment reform. Next slide. As I said earlier, primary care supports is really pivotal and front and center to the work that One Care is doing with its provider partners. This chart here shows the actual, so remember at the beginning of the years there's a potential and there's an actual population health management payments that are made out to our network. Annually the percentage that goes to primary care, which as you can see is high overall because that has been our focus and the number of organizations that are participating and remember hospitals would be 110. So all hospital employed physicians would come in as 110. So if those numbers look low to you, that's why because this is on a tax ID number. That's $138 million that has gone to primary care providers to support their work since 2018 that would not otherwise be available to them absent an ACO construct. Next slide. I'm going to end here on our core capabilities and talk a little. Although this slide doesn't do justice to the work that we've done over the years on diversity, equity, and inclusion, we started at our governance level working with our boards and committees. At their recommendations and through surveys, we've created a committee that is focused solely on health equity and inclusion. The group or the membership that's part of this committee is really focused on those who either have had lived experience or work directly with individuals in underserved areas. So it can help us to develop policies, procedures, and programs to address this work. We actively engage our boards and committees in ongoing training, and we talk at least quarterly, if not more, to our boards about the work and the plan that we are working in diversity, equity, and inclusion. We have been working with our internal staff to think about recruitment strategies to be a more inclusive board and committee in workplace, and that of course will happen over time, but we have some good framework put into place for that. We're working directly with our network to give them data to be able to see where their communities are in terms of diversity, equity, and inclusion's social determinants of health and their overall reporting and program design and how things like food insecurity or housing or poverty might be impacting people's health care. And last but certainly not least, working with our internal staff and employees to first understand where opportunities lay as an organization in diversity, equity, and inclusion, and from there we can build an ongoing plan and training around those opportunities to carry through. That's the end of my presentation. I am going to turn it over to Tom Boris, who is our Vice President of ACO Finances, who is going to walk through the next section of the presentation. Thank you. All right. Hi everyone. My name is Tom Boris, Vice President of Finance for OneCare Vermont. Thank you so much for the opportunity to present today the 2023 budget for OneCare Vermont. For a little bit of orientation, I structure this presentation into two components. The first will focus on ACO program terms, things like attribution, total cost of care, and risk, and then we'll shift into more focus on the OneCare Vermont entity itself and its budget for 2023. Just a reminder to everybody that this is the plan that we developed last summer with best estimates in mind. The program terms in particular are still in active negotiation with the payers, making progress as we proceed towards the end of the calendar year here. And then as Marissa mentioned earlier on in the presentation today, that we will be coming back in the spring to share any differences that represent shifts between what we estimated last summer and what came to bear through these contract negotiations. Slide please. All right. Jumping right in with our value-based care programs, the 2023 budget includes continuation of all the same programs offered in 2022, Medicare, Medicaid, and commercial arrangements. A couple of quick notes on each. For Medicare, we are increasing the risk corridor to 3%. It was 2% in 2022. And we've incorporated the CMS forecast as dictated by the Vermont All-Payer Model as the trend rate for that particular program. For Medicaid, similarly increasing the risk corridor to 3% for the traditional cohort and 2% for the expanded. The difference between those two groups traditional attributes ordinarily through a primary care relationship and the expanded is a geographic style attribution model. I'll speak about this a little bit more as the presentation goes on, but we're collaborating on a fixed payment expansion initiative with Diva, which I'm quite excited about. And then in the commercial arrangements, we are planning to increase risk-sharing terms similarly to the public payers. And the trend rates incorporated follow the improved insurance rates and provider increases naturally occurring in the system. Taking a look at attribution budget estimates 297,000 lives incorporated that's very similar to the level that we have in 2022. 268,000 expected to qualify for SCAM. Couple interesting notes about attribution. We are expecting a slight increase in Medicare attribution due to the incorporation of the St. Johnsbury HSA, which is great news. We do anticipate that Medicare Advantage growth will continue to somewhat offset attribution in this program as Vermonters may choose to move to a Medicare Advantage product rather than traditional Medicare. So there's some opposite or opposing forces going on that particular program. The most noteworthy item in Medicaid is that we expect redetermination to resume during 2023 where they evaluate who is eligible for Medicaid. This was on pause through the pandemic. What this means is that we expect to see higher than normal attribution attrition throughout the year. We don't think this will affect starting attribution, but throughout the year we'll see more and more members taper off as redetermination resumes. Shifting into total cost of care, we use the attribution estimates to prepare these total costs of care projections. $1.4 billion of health care costs and value-based care contracts. That's very similar to last year, largely because we've maintained the same provider network, same attribution base. So staying the course. We do expect, well, all of these targets, total cost of care estimates here stem from attribution estimates, insurance rate increases, and other payer reimbursement modifications. So we largely are following the industry trends to establish our best estimate of these targets. Ultimately, they're determined through actuarial processes with the payers. The Medicare column on the left, you can see that increase due to the addition of St. Johnsbury, as I mentioned previously, and then the ordinary inflationary trend in that program. And then the Medicaid total cost of care, you'll see it actually is going down. That's an impact of redetermination. A little bit more on the program trend rates. Medicare, it's a 5.2% trend per the Medicare, United States per capita cost forecast that is supplied by CMS every spring, as dictated by the all-payer model. Ultimately, that trend rate is at the discretion of the agreement and care board. Medicaid, we based our trend on analyses of prior year trends generated through the actuarial rate development process. We have the benefit of operating this program for a number of years, so we can look back through some historical data as well as emerging trends in healthcare to inform the trend rate in this budget. And then commercial programs informed by the approved rate filings to develop those trends. All right. Underneath these total costs of care arrangements, we have some exciting opportunity to do payment reform where we can change the way providers are paid. Really not a lot of news in the offerings from the payers to OneCare and its provider network. Medicare will continue to be a reconciled to fee-for-service model. Medicaid is an un-reconciled model, which is the structure we prefer. And then for commercial limited offering, but it is reconciled to fee-for-service. We put significant energy into commercial fixed payment expansion for 2023. There's a number of limitations that prevented more significant advancement. And we really put a lot of weight behind expanding the offering for the comprehensive payment reform CPR program practices unsuccessfully. On a more positive note, though OneCare and Medicaid are an active development of a fixed payment expansion initiative. And one of the challenges with doing payment reform underneath an ACO model is that the payment reform is limited or contained to the attributed population. There are always unattributed members or beneficiaries in these programs. So we're working with Diva to think about how can we expand the scope of the fixed payment arrangement to not just look at the attributed population but look more broadly at the entire Medicaid population. The impact of this would be that any provider's Medicaid reimbursement would be more in the fixed payment arrangement and less in a fee-for-service arrangement. And our initial focus is going to be on expanding the lives covered, but not the service set underneath the fixed payment. The service set that are covered by the fixed payments is something that we can look at in a subsequent year, but want to make this really important first step to expand the scope of the population covered by the fixed payment. Next slide. Okay, risk and reward. So under ACO arrangements, there's potential for shared savings or shared losses. Another term for risk and reward. The story here is resuming much more material and I'll call it normal risk sharing levels. Prior to the pandemic, you'll see on the left of the chart here, $42 million of risk. This was our pre-COVID budget. After the pandemic hit, we worked with the payers to modify contract terms to really protect the payers and the providers from high levels of risk and vary on certain times. We lived with risk around $16 million for the past couple of years, and you'll see in 2023, this budget escalates risk quite dramatically back to a more, as I said, normal level of risk. It's sizable, $36.5 million. Next slide, please. Our approach to accountability. Really two elements to how we install accountability amongst the providers participating in OneCare Vermont. One is shared savings and loss, just spoke to a moment ago. The other is through the population health program accountabilities. This is really a macro and micro concept and trying to keep a common thread throughout. Starting with the shared savings and loss, largely remains with the hospitals due to the magnitude that $36 million figure. It gives the hospitals opportunity to offset participation fees. Hospitals fund OneCare Vermont, so this is an opportunity to get that investment back. We pool savings and loss by HSA with HSA level performance factors as we've done in the past, and then the accountability pool incorporates primary care into the risk model across the network. All types of primary care, but at a moderated level that's more aligned with their revenue and the other population health management payments they receive from OneCare Vermont. Moving to the micro side, we have a PHM program, which I'll speak to a little bit more in this presentation that incorporates provider-specific performance-based components, and we heard loud and clear from our provider network that they want their measurements to be things that they can directly control and affect. So having specific measures that give providers meeting or exceeding targets, the opportunity to earn more relative to their peers is really the essence of value-based healthcare. Doing this also enables the financial accountability to align with the size of the investments and that we're not overburdening primary care with risk of a large payback at the end of the year or a very sizable payment even. Next slide, please. A couple of risk management notes for the board. The accountability pool components are expected to apply universally. In the past couple of years, we've only had provider risk for the Medicare and Medicaid programs. As we expand provider risk more broadly to all program offerings, the accountability pool will go with it. We still offer the deferral option for providers electing that particular pathway. We are offering a risk mitigation arrangement for NVRH and the St. Johnsbury HSA as they enter the Medicare program for the first time. We've done this many times as we've grown the one care network. So we are limiting the St. Johnsbury HSA to 1% Medicare risk corridor and one care Vermont is the counterparty to this arrangement meaning that any losses beyond 1% are owed by one care Vermont and any savings beyond one care 1% are payable to one care. If we did have to pay on behalf of St. Johnsbury, one care reserves will be used to fund that obligation. Next, we've made a couple unique accommodations to grow the CPR program. It's been a successful endeavor and want to make sure we can get as much participation as we can. We have not budgeted a reinsurance or reinsurance like arrangement for 2023 and the Medicare financial guarantee of 1% we plan to facilitate the same line of credit arrangement we've used in the past. That section was a high level overview of some of the ACO program terms. Now we're shifting into one care Vermont as an entity. This is my perception of one care, a $45.1 million organization with two main components, $29.9 million in population health management investments. These are payments facilitated by one care directly to the providers to support our shared goals of high quality health care and managed health care costs and then $15.2 million in one care shared infrastructure. We call it shared infrastructure because we are welcoming to all participants and providers who would like to be a part of these value based care programs. Couple of notes, it's a balanced budget, no profit or loss and no additional contribution to one care reserves incorporated and the two key elements they'll speak to in a few moments. Transition to the new population health management program financial model and work reconfiguration. We've reduced office space to align with our primarily remote work model and redesigned analytics support. Looking at revenue notes, please to say there's not a lot here, which is a good sign if you ask me. Budget includes consistent reform investments through payer contracts. Often there's a PMPM per attributed life paid to one care that we can then use to invest in the providers or provide incentives. The revenue levels flow with attribution but we expect the models in place in 2022 to largely remain the same and just flow into 2023. A little bit of nuance to the next one. There's a potential incorporation of a $2 million Medicaid value based incentive funding pool. In 2022, Medicaid is making available to providers $2 million for the value based incentive fund but it's paid directly from Medicaid to the providers. In other words, it does not flow through one care's entity, business entity. When this budget was being developed, we weren't certain whether that model would stay in place or if the funds would actually begin to flow through one care so that we can align payments more seamlessly to the providers. What we chose to do here is incorporate a $2 million unsecured revenue line and that means we could then show on the expense side the full boat of population health management payments that we intend to provide to the providers. A potential that exists is that Medicaid will retain that $2 million pool and pay those providers directly. If that were to occur, we would simply remove the $2 million unsecured revenue line and in a corresponding and balanced way remove $2 million of population health management expense as that will be paid directly by Medicare and outside of one care Vermont. Either case, isn't that neutral to the one care bottom line? It just reflects the way in which the funds will flow. And then the last bullet here, a $205,000 or 1% increase in hospital participation fees. Again, the hospitals fund one care Vermont so we're always very mindful of the impact that the one care budget has on those hospitals. Here's the numbers for the revenue. You can see the payer program support going up by $1.6 million. Part of that is the $2 million unsecured revenue. So if those funds do not flow through one care, we'd simply back that $2 million out. You can see next the shared savings to fund the blueprint. The $472,000 change reflects the inflationary impact applying that 5.2% to the advanced shared savings line in our budget. And then the other notable number, other revenues, you'll see a pretty sharp decrease of $1.4 million. This reflects use of deferred funds largely in 2022 that we don't expect to use again in 2023. The pool of deferred funding grew through the pandemic as priorities shifted. And in 2022's business, we've committed to pushing a lot of those funds out to the providers. All right, shifting to the expense side, I've broken this down into two components as well. The first being population health management. The big change that we had to incorporate in this year's budget was the evolution of the new population health management program. It was designed to be a consolidation where we took the historical 325 PMPMs, paid to primary care, care coordination funding, and value-based incentive fund funding into the new model. When we did this, we really put a lot of emphasis on sustaining base payments to providers right now. That was important to keep some consistency and regular cash flow to the participating organizations. And then we also wanted to incorporate universally bonus potential based on quality and outcomes. So this is where any individual provider can earn this bonus payment based on achieving preset benchmarks. This also gives us the ability to enhance accountability in future years. There's a proportion of base payments to bonus payments. That's a split that we can move over time to put more emphasis and focus on achieving those quality and cost outcomes that we'd all like to see. Continuing with the CPR program, $5 PMPM Incorporated, we've done some work with the CPR Clinical Advisory Group to establish clear accountabilities. I'll speak more about CPR in a few moments. And then Bud Blueprint, as I mentioned before, budgeted at the all-payer model trend of 5.2%.  So to speak to the Population Health Management Program in a little bit more detail, this first slide focuses on the primary care component. And in a moment, I'll speak about the designated agencies, Home Health and AAAs. We break these two apart because of attribution. Primary care attributes providers directly. So we can do PMPM payments, whereas the other provider types don't attribute in the traditional sense. So we have slightly different arrangements to fit their structure. So you can see in the base payment section of the chart in the middle of the page, combining the historical 3.25 PMPM and the $1.50 PMPM for care coordination into a single blended PHM-based payment of 4.75. So designed to be net-neutral and even for the providers. Then for the bonus opportunity component, we looked at historical care coordination bonus earnings and VBIF earnings, again, both for primary care. And we rounded it up to a nice clean number of $1.00 PMPM for the bonus. One of the reasons we could round up without increasing hospital dues, for example, or participation fees, is that not every participant will maximize that $1.00 PMPM of bonus. We estimated that about 80% will earn the bonus payment, but we're going to learn a lot during 20s about the rate that these providers meet those targets. Next slide. So focusing on the DA's area agencies on aging and Home Health agencies, same concept really, consolidating prior care coordination and value-based incentive payments into one stream. In alignment with the primary care model, 85% of the pool will be paid as base, 15% as bonus opportunity. That's the same proportion that exists in 2022, and largely the same measures as 2022 so that there's consistency throughout these years. A little less finalized at this point, but before the budget was submitted, Diva expressed interest in the mental health and substance use disorder areas, and we agreed to put a $500,000 expense component for this important topic. We're still working on the specific nature of the initiative, but happy that we have some funds in the budget to invest in this area. All right, CPR program. CPR program is the Comprehensive Payment Reform Program. This is a payer blended fixed payment model that one care can offer to independent primary care. We've been offering this program since 2018, and as Vicki said earlier in the presentation, it's grown substantially, and we now have 19 sites participating in 2023. The change that we've incorporated this year is to link primary care reimbursement through the CPR program to the total cost of care. The purpose of this is to have primary care reimbursement more closely tied with macro-level health care cost growth trends. What we've seen in the past is that health care costs at the top level continue to go up, and primary care reimbursement has not kept pace. So this is an opportunity to maintain a linkage so that if the total cost of care grows substantially or even modestly over time, primary care reimbursement will follow along so that they are receiving a similar portion of the pie that you see on the right. This also helps us establish a baseline. We can really evaluate where are we now relative to the total cost of care in Vermont as a starting point and then build towards a level that we find is appropriate into the future. There are a couple of challenges with this arrangement as well that that would be important to share. First, the total cost of care is variable, so we're making primary care reimbursement linked to the total cost of care, and we do not know what next year's level will be or the year after, so there's a level of disuncertainty that comes with that. And then second is that the percentage of total cost of care for primary care works cleanly when you're looking at it through one payroll, and you can look at Medicaid, for example, and say in Medicaid primary care receives X percent of the total cost of care, and you can do the same in Medicare and the same in commercial. Where it gets challenging though is when you start to blend across payer lines. Try, and this is a payer blended model where there's a singular fixed payment across all their population, so we've had to put a lot of thought into how to make this fair and balanced for any provider regardless of their payer mix, of their Medicare heavy practice or pediatric practice, for example, that the arrangement that we built works fairly for all different types. Accountabilities, we're still working on the details, but we're getting quite close, but our vision is that providers can reach different tiers of reimbursement based on actions and outcomes. While not finalized, we think that some sort of a mental health integration into primary care is likely to be a component of this that would allow a practice to reach a different tier of strata reimbursement. And then importantly, participation in ongoing program evaluation, putting a lot of emphasis here is an important element as well. Opportunities for this program to continue to grow and be successful. Expand payer participation with unreconciled fixed payments. I mentioned earlier on some challenges in that space. Expansion to other types of primary care. We have done a lot of work on potentially applying this onto FQHCs, and we're actively looking at whether this could be installed over hospital-employed primary care sites. It's a little bit challenging in that space because of the way the billing works, but I do think that there is some opportunity to do that. Continued refinement of accountabilities will be important as we move forward and then, again, program evaluation, an important element. Next two slides are largely just for reference here. We take the just shy of $30 million in population health management investments and break them down into two different ways. This first slide looks at the investment area or program, if you will. So you can see the top two rows, the population health management program, base payments, and then the population health management program bonus payments. And if we shift to the next slide, same numbers, except it's broken down by provider types. You can see which organizational type is receiving these funds and through which programs. All right, another transition point, shifting off of the population health management expenses and onto the operations. This is really the one care Vermont entity that makes all of this possible. The two notable changes that I referenced earlier was redesign of analytics support. This is in partnership with the UVM Health Network to make sure we have a high quality and efficient analytics engine to support this work. It's a phased approach, and what we've done is designed this to be net neutral to one care Vermont in 2023. So it neither costs more nor less to us, but we will evaluate continuously as this transition rolls out. And for the 2024 budget, hopefully we start to be to see some of the efficiencies or economies of scale that we can gain through this transition. Next work reconfiguration. We've reduced our office space to reflect a primarily remote work configuration. Took us a little bit to get there through the pandemic, but we committed to this new structure and reduced our footprint accordingly. And then other expenses have been reduced to align with this remote work model through the pandemic. We weren't sure if we'd come back to being in person largely or remain remote, but now we're more committed to this remote model and have made adjustments accordingly. To show the numbers, $248,000 expense reduction for one care Vermont, about 1.6%. You'll see in the table above many categorical shifts. This is largely from the restructuring of the analytics support with UVM Health Network. For example, you see salaries, payroll, and fringe going down, but that's offset by an increase in the purchase services. It's replaced dollar for dollar with a services contract from the UVM Health Network. So a lot of juggling between the different buckets, but most of it is related to this analytics transition. Not a discrete row on the table above, but reducing our rent or our office space saved 373,000 in rent and utilities. The chart on the left shows operating costs over time. You can see pretty aggressive growth between 2018-19 and the 2020 pre-COVID budget. This is when one care was exploding with growth. We reduced quite drastically after the pandemic hit right around this $15 million level and have maintained this level largely to avoid having more costs borne by the hospitals. There's always more we can do at one care, but again, being thoughtful of the cost place in Vermont hospitals. A couple quick notes on staffing. The most significant change is on the rightmost bars of the table here. It's a value-based care category. This is a combined some historical groupings that we've shown in the past, analytics, prevention, care coordination quality are now kind of merging under one org chart. The reduction to that area reflects the analytics transition, those staffing moving from one care of Vermont to the UVM Health Network. Outside of that change, there really aren't a lot of other substantive changes. There's a couple of shifts that they're more organic. Somebody's role has evolved a little bit or moving to a different department, but not a lot of change overall to the staffing model within one care of Vermont. I'd like to show this one every year too. This is the one care operating cost as a percentage of the total cost of care continues to decline. This to me just shows the economies of scale that are achieved through this singular model where we can just bring more providers in, more attributed lives onto the same platform and chassis of expense. Next slide. Very simple income statement for one care of Vermont here. You can see on the revenue side, if you will, the total cost of care targets, 1.4 billion. It's not one care revenue. Those are existing healthcare dollars that are now in a value-based care arrangement. Next, payer contract revenue, about 12 million. Other revenues, 3.6 and hospital participation fees of 19.8. On the expense side, you have the health services, 1.4 billion. Again, note the difference between that number and the number under the total cost of care targets is the blueprint advanced shared savings component. Population health management investments, 29.9 million and then the operating costs of 15.2 and again, the loss of zero dollars. The pie on the right shows that in this budget, 96.9 percent existing healthcare dollars paid either directly to providers or through a fixed payment. So no real change in the industry or system in that part, but then supplemented by 2.1 percent in population health management investments and then 1 percent in the one care operation itself. Last slide for me. I know it's tiny. Apologize, but wanted to put in a more robust income statement and balance sheet and just use this as a backdrop to say there are lots of Excel files on the Green Mountain Care Board website for the public to review in many different perspectives and depths. So I invite everybody to go there and take a deeper look if you're interested and curious. And that concludes my section. So on to Kerry. Hey, just interrupt real quick. Thank you. I think the pace picked up a little bit, but just watching the time, it's been about 50 minutes. And if we need to go a little bit into lunch and spill over past an hour, we can. But we've been about 50 minutes so far. Thank you. Hi. Good morning. I'm going to make comments on budget section seven, ACO quality, population health, model of care and community integration. Next slide, please. Last year, we committed to the goals that you see here, many of which have already been mentioned by Vicki or Tom, so I won't read through them. We'll talk about them in the next few slides. Let's go ahead, please. So as we committed last year, we developed a new committee structure this year, and it aligns with our three core capabilities that we identified in our 2021 strategic plan. And just to restate those, network performance management, data and analytics, and payment reform. If you see the row with the three turquoise boxes here, those represent these three core capabilities. And then moving on down in this diagram, we show you the work groups that we have developed. We wanted more input from our provider network in foundational creative and tactical thought processing. So we invited them to participate in these work groups that you see here, and we got a lot of work done by doing this. We gained a lot of input across our network as well. We had the ACO wide participation and engagement over the year with ongoing attention to diversity and inclusion across all groups. Subcommittees and work groups have charters and all but a couple of these groups that you saw on the last slide. Yes, go ahead, please. Have met at least once this year. And as a result, we've made rapid progress on important developments and decisions such as this list here. Quality measure selection, disparities, scorecard development, clinical prevention topics, care coordination activities, and CPR developments, which you just heard about from Tom. We strive to be all inclusive in membership. And this includes seeking participation from our patient and family advisory council, which meets once a month. And members from that council are invited to participate in all of these groups. We now are seeing interest from a variety of organizational members who have actually been asking us if they can participate in one of these groups. Next slide. We are committed to continuously increasing our engagement and relationships with our network. This year, we wanted a fresh approach and reformatted our health service area consultations. And Vicki told you something about that already. The new template that we develop aims to deliver both data and insights or direction, and then also to invite dialogue about key findings in an effort to stimulate and support action. These sessions have increased attendance and conversation and are followed by coaching and support at the local HSA population health level with the teams there to work on quality improvement projects which are identified throughout this process. And we develop a mutual plan and have touchpoint sessions with the HSAs at the local level on a regular basis. HSA teams have been and will continue to be invited to our Board of Managers meetings to show off their work and get feedback. The Bendington HSA and also an independent primary care team presented this year so far in the public sessions of two different board meetings. This helps foster transparency, awareness, and engagement. Next slide. As you already heard, we are advancing our population health model framework moving from an individual PHM program type of structure with some accountabilities into a blended model with advancing accountabilities throughout 23 to 25. Next slide, please. This new model drives us forward into evolving value-based payments and requiring care coordination and collaboration across the HSA care continuum to unlock funds and it also pushes quality improvement. This program will gradually shift away from base payments and towards increasing accountability-related payments. We purposefully chose metrics for 23 that are claims-based rather than manual abstraction metrics and therefore can include the entire attributed population. Next slide. Our 2021 quality results show that we are doing well in diabetes control, reaching or maintaining the 90th percentile for that metric across all payers. We also show strengths in follow-up after ED discharge for both mental health as well as alcohol and other drug dependence and also we show strengths on an ongoing basis in the area of child and adolescent well-care. We have opportunities in areas of hypertension control, depression screening and follow-up, and the initiation and engagement of alcohol and other drug dependence treatment. We are using these results to set goals for our 2023 PHM and to continue to raise the bar on value. We promote a mindset that care coordination and prevention are common threads throughout our network's clinical work and they impact our success in all areas. Care Navigator, a software platform used to document shared care plans, will sunset at the end of 2022 and no longer be required for documentation by our members. We continue now and will for 2023 to support and hold our members accountable for care managing high and very high risk patients and patients in areas of focus such as high social and medical risk, high ED and inpatient utilizers, and those with high total cost of care. We are requiring our members to have triennial reporting for care coordination and to review with our oversight team what they are doing at regular intervals. We did a survey in 2021 of those patients across our network who were care managed and got positive responses about the care coordination they received. They were pleased with their engagement in their shared care plans, with communication, and with having lead coordinators. We are incentivizing HSA-wide care coordination teamwork via our 2023 population health model, as you already heard. The population health model also incentivizes prevention by setting quality targets for preventive visits, timely follow-up in control of chronic disease and health screenings as well. Our data and analytics team has developed and is deploying a health disparities scorecard using data-driven gap analysis that shows great promise for supporting local communities in focusing on the intersections between medical risk, healthcare access, and social determinants of health. So that is in an iterative state and we're very excited about how that's going to aid us going forward. Next slide please. This diagram we just developed to depict how all of the work that I just described is interrelated and brings us closer to our primary outcome goals of improved population health and lower healthcare costs. Each gear wheel shown keeps the other turning and it takes the various cogs to make it all work together. As all partners in the care continuum implement change at different points of care, we can move towards our goals. We believe that our organization remains a valuable catalyst in helping transform the healthcare delivery system in Vermont. Thank you and I will pass it over to Sarah, our COO, to talk about evaluation and performance benchmarking. Good morning and thank you Dr. Wolfman. So I'll be quite brief and just want to start by noting that the Green Mountain Care Board has invited one care and payers involved in ACO activities to a session later in November to review and discuss in detail our quality and financial performance. So we've not repeated that information here. If you could advance the slide please. So briefly I wanted to highlight some of the evaluation activities that we are focusing on this year. Some of the initial results and findings that we're seeing and then I'll end by speaking about some of the areas that we need to focus on in the year to come. So at a high level you've heard a theme throughout this presentation of evolving our population health model and that really began with some key inputs as Dr. Wolfman mentioned looking at our quality opportunities but also our care coordination program and some of the findings that we were seeing and some of the challenges that people were telling us about from our network. So we used those as a platform to really think about how to evolve that program and ultimately to inform the selection of the specific quality metrics that will be incentivized for payment in the year to come. In addition the beginning of 2022 we embarked on two large endeavors. The first was a contract that we initiated with the University of Vermont Health Services research team to help us scan the literature and identify evidence-based measures out there that we could consider as an ACO to inform a set of key performance indicators across a variety of domains including cost and utilization, looking at outcomes, engagement, etc. And that process has resulted in a set of measures that will be going through One Care's governance committees later in December and ultimately our goal is to align them with the Medicare benchmarking analysis that I'll speak of in just a moment. The second thing that we asked for assistance with from this Health Services research team was again scanning the national environment and helping us to identify whether there was a provider satisfaction survey that could help us understand the expectations and performance of One Care from the lens of our network participants. And through that process unfortunately there was not a known instrument that could be identified that would address some of those key questions and so the UVM HSR team actually developed an instrument. It focused on really understanding the perceived usefulness and ease of use of some of the tools and supports that One Care provides to our network as well as providers knowledge and understanding about One Care and overall health care reform and their experiences thus far. Because this was a new instrument it was determined that the appropriate next step was actually to pilot it with a small group and so over the last couple of months we've deployed that survey to primary care providers in a sample and we have responses now across the state from our 14 health service areas with just about 80 primary care providers. And I'll speak in a moment to a couple of the early indications that are coming out from that survey. And then in response to the Green Mountain Care Board's budget order to One Care for 2022 One Care embarked on a finding a vendor and working very diligently to create a Medicare benchmarking analysis platform that would really bring together a key cost utilization and quality metrics. And in doing so the vendor pulled 100% of the Medicare population fee for service national data set that initially included over 500 ACOs. They developed an algorithm to identify a peer group of ACOs on a set of robust criteria that meant that we were comparing apples to apples. So things like ACOs that were in two-sided risk programs for the Medicare program. And the result from that is a cohort of about 20 ACOs nationally that One Care can be benchmarked against to understand current performance both strengths and opportunities. It is important to note that in using that data set there was a tremendous amount of work that needed to be done to risk adjust and adjust the unit cost and normalize that data so that it actually makes sense and can be applied in the state of Vermont and in our context. And then finally I won't go into detail now but it's been noted that within our CPR program some qualitative evaluation work has begun and more quantitative work is planned in the months to come. Next slide please. So this could go on for hours both in terms of strengths and opportunities but I pulled just a couple of key highlights that I think are worth noting from some of the efforts I just mentioned and to start at the top with the new Medicare benchmarking analysis we have been able to see consistently that One Care is lower cost than other peer ACOs nationally and while that varies a little bit from year to year from the years 2019 to 2021 it ranges from 9 to 14 percent lower cost overall. Similarly preference sensitive conditions these are things like somebody choosing to have a knee or hip replacement spinal fusion or coronary artery bypass graft those are often choices driven by consumer preference and One Care as a statewide ACO demonstrates results that generally are 20 to 80 percent lower than the national ACO peer cohort. That's not to say that there are opportunities for improvement and I'll get to those in just a moment. In the pilot survey data that I was discussing a moment ago one of the interesting early findings is that from independent primary care providers responding they indicated that they understood how One Care supports critical aspects of the work that they're conducting with their patients that their work would be more difficult without One Care in its support and that ultimately the quality of care they're delivering has improved through their participation in One Care. It is interesting for us to note that it stands out that that comes from the voice of independent primary care providers who are most likely more aligned with our CPR program and some of the advancements there and that there is some work to be done to help our colleagues in other primary care sectors to continue to understand and advance some of the value proposition that then through One Care they're able to deliver to their patients. And finally through CPR again flexibility predictability and enhanced payments are themes that we heard through that qualitative evaluation. With respect to opportunities again reverting back to the benchmarking data we saw some pretty significantly higher use of the emergency department than other national peer ACOs and we also saw opportunities to continue to maximize the role of primary care that some of those services were lower utilized than in other parts of the country and in other similar ACOs. Similarly there's some pretty complex data emerging around post-acute care transitions where we're seeing some higher lengths of stay some higher costs and higher admissions but interestingly we're also seeing lower use of inpatient rehab better use of home health and so there are some exploratory conversations going on around whether in Vermont perhaps there is a better use of appropriate care settings based on patient need and desire. So more work to be done to really evaluate and understand that data further and to continue to work on transitions of care particularly from inpatient to outpatient settings. And then finally in the context of that survey advancing provider education to improve general understanding and ultimately to reduce some of the complexity that is involved in Vermont's healthcare reform efforts and in advancing some of the payments and care delivery transformations. Next slide please. So finally these are really early days when it comes to some of the evaluation and data and findings and so there's much more work for one care in the team to expand upon as we move into 2023. Some of the areas are highlighted here and I spoke to them a moment ago and it encompasses lining our key performance indicators with those benchmarking reports and pushing that information out deeply into our network so that they understand performance opportunities and have systems and supports to help facilitate improvements in those areas. Continuing to advance our provider survey, our CPR evaluation and as Vicki said at the top of this session to really use all of the data that we are finding here to inform our strategic plan refresh in the next quarter of 2023. And all of this work will be supported through the one new hire that we've planned as a program evaluator that we are hoping to move forward with early in 2023. So with that brief overview of some of our evaluation activities I'll now turn it back to Vicki to provide some final remarks. Thanks Sarah. I'll just close by wrapping up and saying our 2023 budget at the start of the hour was really to focus on our mission as an ACO and with a keen laser focus on what our board and our leadership has determined to be our core capabilities and those are the things that OneCare can really execute on in terms of the contracting, the data and analytics and the payment reform mechanisms. And we with our provider partners who are the ones who can really do the delivery system reform aspects. We can install the payment reforms. Our participating providers are the ones that can really impact the care delivery part. Really are working together as a system to support patients the best care, the right time, the right place. Thank you. Thank you all and really wonderful graphics on your slides. I'll turn it over now to our staff and Ms. Melamed for their staff questions. Thank you. Thank you Mr. Chair and thank you to the OneCare team for the presentation. I'm going to kick it off with some questions from the staff. So our first question is around OneCare's risk model could be referenced to slide 20 and you're talking about the $36.5 million worth of risk. So in OneCare's model the long-standing risk model has been to delegate the risk out to the provider organization. And this we view as the ACO as an entity is taking only the OneCare as an entity is taking on only minimal risk. So you mentioned some risk mitigation for some hospitals I think at about $800,000 or something this year it's buried over the years. OneCare is making the choice to delegate all the risk and pass on all the settlement to its participant hospitals. Does OneCare continue to believe that delegating all the risk to hospitals is the best strategy and please explain why as opposed to holding more of it as an entity? I guess that but that mercy characterized it correctly that we do delegate or pass through the risk to providers. You know every once in a while we discuss or talk about whether or not it would make sense for OneCare to hold more risk but ultimately it's the health care providers that are the ones that will help generate these savings. I mean OneCare tries to install the framework use data effectively implement payment reforms to help them in that endeavor but at the end of the day it's their hard work delivering the health care that should be rewarded and that tends to be the the concept or theme that that takes the most hold to it. It also adds some stability for us and that we have the hospital participation fee model where OneCare is effectively funded and there's no kind of organizational risk that we wouldn't earn shared savings in a year and all of a sudden find OneCare as a business entity in a tough financial predicament. Okay thank you. I have a couple questions now on the on the payer contracts and in network. Can you provide any insight as to why Mount Ascutany left the Blue Cross Blue Shield Vermont program for 23? I can take that question. This is Sarah Barry. My understanding is that there are several exceptions that the board approved related to complete participation in programs and by and large the reason had to do with electronic health record conversions or other large operational changes that were happening within the hospital system that were making it difficult for them to continue to accurately identify specific cohorts and take increasing risk and so in each conversation that the board had in managing those requests they considered kind of for how long this request might go on and were there indications that there would be an end point in site and the intention is that there is although it varies from one organization to the next. Okay thank you. The Green Mountain Care Board requires actuarial certifications to be submitted by OneCare for each commercial benchmark stating that the benchmark is adequate but not excessive. Actuarial certifications are required because the financial targets for commercial ACL programs are typically not finalized until after the board issues the budget order. In prior years the Green Mountain Care Board approved budgets reflecting yet to be negotiated commercial targets provided targets met certain requirements including that the targets be certified by an actuary as adequate but not excessive. We understand from your responses that OneCare's position that it is not the proper entity to supply this certification the OneCare FY23 budget includes a return to more traditional risk sharing models for commercial programs as you stated so adequate target setting methodology is even more relevant. So my question about these certifications is what data does the consulting actuary receive and explain why it is or is not sufficient to provide an actuarial certification from your perspective? That varies by payer programs. Some payers offer us modeling data sets that we can use and we rely upon our consulting actuaries to evaluate the sufficiency of the target using the modeling data. In other cases most cases we actually don't receive that modeling data set so what our actuaries opine on is the model itself. Is there bias? Is there anything that is unfair to either party frankly in it and you know at the end of the day it's that the target is set by error they typically have well they often if not always have vastly more data than we do so it's always a little bit of a leap of faith OneCare enters into an arrangement but we do it very thoroughly and deliberately with the actuaries to ensure that we think the target is fairly set. And has the ACA reviewed this budget order requirement and actually and gone to this actual review with the commercial insurers? Like have you shared what your process is with them and discussed this requirement with them? Yeah I mean they've supplied certifications for us in the past it's always a tricky conversation with their actuaries because again they don't have the data so a little bit difficult for them to certify specifically the target but they do certify the model itself do they think that the target will be excessive and then they also look at the nature of the risk arrangement to determine whether or not there's any risk on the solvency of OneCare Vermont. Okay thank you. I'm going to move on to a couple of questions about the analytics transition and the relationship with the University of Vermont Health Network. My first question is probably references slide 34 from your presentation but the question is what is the can you tell us what the total value of OneCare's contract with UVM for analytic services is? We cannot release that in the public but we're happy to share it privately with the Green Mountain Care Board and Health Care Advocate. Okay thank you because we're trying to track the transition and from the income statement there's a two million dollar change in contracted purchase services but the decrease in software line is about 800k so I'm sure these don't line up and it's unclear to us what the total value of that is. I was going to say Marcia we can say generally to you because this was something that our Board of Managers required as part of this transition that it is budget neutral for OneCare Vermont and is not representing a cost increase to be able to transition to this system which is very impressive considering we're having to operate two dual systems right now as we transition to a new software. Okay that was my follow-up question if there were added costs and it sounds like the answer. There are not added costs. Okay so we just might need some help tracking how the line items moved from one line to the next and then the total value of that contract when it's available. So the second part of the question then is that the Green Mountain Care Board has requested the copies agreement with the University of Vermont Health Network to provide these services within five business days have executed. Has this contract been executed yet and when do you expect to provide it to the board. Thank you for the question. Yes the contracts have been executed and I am waiting for redacted versions to come out of our legal office which should be any day and we will get those to you immediately. Okay thank you. Then we have another follow-up on this around the responses to the written question so you described some of the data security measures that OneCare and the University of Vermont Health Network will take as OneCare data and analytics move to the University of Vermont Health Network. We had an additional question if you could please further discuss how OneCare and the network will prevent any anti-competitive conduct and handle any conflicts of interest that could arise from UVM managing data from providers that compete with UVM and payers competing with UVM and the MVP Medicare Advantage plan. Sure I can take that at a high level and then once we've shared the contract if there are additional questions that arise from some of those details we'd be happy to answer those as well. Globally as we have structured this agreement OneCare is responsible to our payers to our network through our data use agreements to ensure the appropriate segmentation and use of any data and through that OneCare has established a set of policies that span compliance data use privacy etc so all of OneCare's policies will continue to control the arrangement with the UVM health network as a vendor supporting these activities. OneCare staff so someone remaining on the OneCare team will vet all of those data requests ensure that they are compliant with those terms and then move data request forward through the system to actually have it operationalized. In terms of data storage and protection we have required the UVM health network to establish some additional policies and procedures those are some of them still in process right now but again we would be happy to share them appropriately as soon as they're available and those are things that are for example maintaining user accessing the system so user permissioning systems where OneCare has control of who has that access and what level that access will be determined at, partitioning data, the staff that are transitioning from OneCare to the data management office at the UVM health network will at work solely on OneCare data so they will not be conflicted in the sense that they might be asked to perform analyses for the UVM health network and their business plans while also being asked to participate in OneCare analyses those things will be completely segmented. If there are additional questions again I'm happy to attempt to answer them now and we will follow up with more detail. Sarah the only thing I add to that and for Marissa to know is that we've outlined at a high level the governance policies and procedures and processes overall that are being used to protect data and that has been provided to our network at large as well as the healthcare advocates and other interested parties so that is a publicly available document right now. It's available on your website or how is it publicly available? It's available on our portal for all of our participants right now and we've made it available upon request to any other entity and anticipated those that might be interested. Okay thank you that is helpful. I'm going to move on to some questions around staffing and compensation. The budget guidance asked for the amounts of both projected base pay and projected variable compensation for OneCare management positions in 2022 so projected 2022 compensation. OneCare only provided one amount for each position that's in tab 6.7 of the budget guidance workbook. Are these amounts base pay or base pay plus variable compensation? They would be both and if you'd like that segmentation we'd happily supply it. Okay yes please so if there are assumptions in those projections around variable compensation what are those assumptions? I assume that that isn't final. What are those assumptions based on? Based on past performance or earning potential under the goal structure that we have for leaders. So from the 2022 to 2023 budget total FTEs decreased overall by more than 10 which you showed on your slide 35 and total salaries and benefits decreased from 9.4 million to 8.7 million so 7% decrease or $664,000 approximately. However executive leadership compensation appears to increase by 20 to 30% between the FY22 submitted budget and the FY22 projections that are included in this year's submission. So we compared what you submitted on tab 6.7 for last year to tab the same tab for this year and if you could please explain this differential we don't see it in the variance analysis any explanation of the change in salaries. I'd have to see the data in a little bit more depth but my initial instinct is that it probably has some sort of an impact related to when certain leaders were onboarded into OneCare and last year's projection may have had partial years for some who were not on the team for the entire year but I'm happy to look at that as well. Okay I'll send over the comparison we can talk it through. Does OneCare have a policy that formally outlines how variable compensation is applied so a policy that's been formally adopted through your committees and board. So we're calm or I said this is Vicki Loner for the record that all OneCare employees are actually UVM medical center employees and our compensation plan follows the UVM medical center compensation plan. So including the variable compensation metrics that you have described to the board in compliance with our guidance on executive compensation. The process yes the goals of course are different because we perform different functions. Okay thank you. And then looking at the FY23 budget again we did ask you to provide projected 22 salaries our executive and leadership salary increases included in the in the FY23 budget. Are there any increases budgeted? There are kind of typical cost of living increases incorporated into the budget which again I can give you the exact figures but it's a little bit complicated because we're all UVM medical center employees on the UVM fiscal year and we operate on the OneCare fiscal year but they're roughly in the 3% range as incorporated into the budget. And is there similar adjustments in compensation for OneCare employees below the executive and management level? Yep we apply the the budget increase kind of uniformly across the all the employees. Thank you. I have a couple questions now on the benchmarking and evaluation information. The first one is in regards to a condition that's been in the OneCare budget order for several years I think back to 2019. The budget order has included a condition that states over the duration of the all-payer model agreement OneCare's administrative expenses must be less than the healthcare savings including an estimate of cost avoidance and the value of improved health projected to be generated through the model. What steps has OneCare taken to measure the value of healthcare savings and return on investment of its programs through improved health and outcomes over the duration of the all-payer model agreement so far so from 2018 through 2022?  Sure I mean there's one reference point we can look at the shared savings earned by the providers but again that's a the providers have earned those funds in my opinion. You know we've had challenges with this conceptual question because I think there are a lot of benefits to having value-based care programs available to Vermont providers and quantifying that benefit broadly to us as a a state to all of our residents is is really challenging and also isolating it to a period of time is challenging as well as we hope that what we're doing here by installing value-based care programs really trying to turn healthcare into a high-functioning system that the real value will materialize in you know 10 years or 20 years and that we have a much more effective healthcare system as the state ages and so it's been a really tough question for us to wrestle with frankly. Marissa I was just sorry Marissa on the stick again. I was going to add to that that through the Alpera model program which One Care Vermont is really the only ACO in the state that is participating in that program the federal government has hired an independent evaluator nor through the University of Chicago to provide a qualitative and quantitative analysis of those findings. We all did receive a report showing promising signs in the first two years I understand that the next report will be coming out shortly as well and that does include findings of One Care and its network for the duration of the Alpera model so I would also say that that is a point of reference for the value of ACOs in Vermont largely but not the same as the Alpera model which is really a state-led agreement. Okay thank you. I'll pause longer before I move on to my next question to make sure that you all have been able to get your responses in. As we consider this I'll just make a comment here as we consider this particular condition which has been long-standing we are you know as people know coming to the end of the original agreement so we have to consider how to interpret that condition if we are you know if we're looking for that measurement to come at the end of this year or if we want to extend that but we need to reconsider that condition for this year's review. The next couple of questions are around the new One Care Medicare program performance benchmarking report that came out of last year's budget order and review that Sarah Berry touched on during your presentation. So in order to be able to rely on that report for performance assessment the Green Mountain Care Board needs to understand the limitations and potential biases of the comparison cohort. You stated that the broad comparison cohort includes 20 out of over 500 ACOs in the Medicare ACO data set and approximately 700,000 attributed beneficiaries total with an average ACO size of about 33,000 if based on the average member months divided by the 20 ACO so that would be 33,000 Medicare lives. Do the selection criteria that your vendor went whether that you worked out with your vendor include other ACOs with multi-payer contracts or are the comparison ACOs Medicare only? Marissa I would want to confirm with our vendor but based on the discussions that we've had it would be any ACO that had a Medicare contract and then per the criteria that we outlined in our summary memo they the vendor independently identified five criteria for the purposes of matching and finding like ACOs and just at a high level. It included narrowing it down to those involved in two-sided risk programs those that were considered to be high revenue ACOs which was really defined as those that had an ACO network that included hospital-based services not only say SNF or only primary care. They looked at an urban rural distribution because they felt that an entirely urban for example ACO would not be a like-to-like comparison. They looked fairly grossly at the specialty network composition and then finally they looked at the proportion of duly enrolled Medicare and Medicaid beneficiaries represented in the ACO. If there are additional questions that the board or the staff would like to ask we're happy to facilitate that process but that's pretty much the limit of what we know and understand about how that matching criteria was constructed by the vendor. Yeah I understand you've provided those criteria to us we appreciate it we just had some sort of additional questions about how that was done and we may take you up on talking about that further but I had another just question around those lines which again your your answer might be the same but I'll state it anyway for the record. So Vermont obviously is a small state but one care as a statewide ACO is large relative to ACOs nationally with over 250,000 lives attributed statewide and that includes over 60,000 Medicare lives which is you know if you were to do a rough average maybe twice the size as as the comparison cohort potentially did the vendor do you know and you can defer if you if you're not sure but did they consider size as an attributed population as part of the selection criteria? I'm not aware that they did but we can certainly follow up and ask them explicitly. Okay and and and one more along that line is does the comparison group include any similar size ACOs so did it look at other you know ones with similar Medicare population similar size overall? Again I don't know but happy to ask. Okay the next one is probably going to be the same same answer but I would imagine can you we're also wondering if you can provide for us a step down diagram of the number of ACOs that were excluded after each criteria was applied so how you started at 500 and got to 20? We don't have that we can ask our vendor for it they may request confidentiality regarding their algorithm but I would assume that we would be able to get that information to you and I also just to say it out loud don't know the order in which those steps were applied so we can find that out as well. Great one more along those lines we also be looking for a side-by-side of demographic factors like age gender you did mention urban rural acuity between one cares Medicare aligned beneficiaries to the national average from the comparison group. This may also include risk scores and again we can talk with you outside the hearing about how to get some of this information. Yeah I think if you could provide us with a list of what you'd like to see we can certainly go back to the vendor and ask what's available and what the timeline would be. Okay thank you. Finally on this still in the comparison cohort one care and its vendor have elected to include the in the benchmark report a 90th percentile benchmark that selects two ACOs with overall success controlling costs rather than identifying the high performance or 90th percentile for each measure included in the measure set this needs that for some of the measures the results are presented as the 90th percentile sorry presented as the 90th percentile are in fact lower than the median performers so it fails to give one care and others an accurate sense of the potential ceiling for high performance. Do you know why one care and its vendor made this choice and does one care believe that having you know just two ACOs as the benchmark group is you know gives it enough sort of power and comparison. So just to be clear we one care did not independently ask for the 90th percentile we felt that that was a part of the budget order and was requested specifically by the Green Mountain Care Board which is why that was produced. We did not have any input into the methodology that the vendor used to develop that it was presented to us as a strategy and as it was discussed with us in the overall template the vendor noted some concerns about that 90th percentile not so much for the reasons that you were describing about the individual measures but because inherent in the fact that that represents the average of two ACOs it becomes more volatile to your point it also doesn't necessarily respect the differences in the markets in which the ACOs are performing the availability of services the types of services consumer preference and utilization patterns so it gets pretty complicated pretty quickly. Ultimately our vendor recommended to us at one care that the most appropriate benchmark comparison is to use the national peer group and so while we've only had this data a very short time that's what we're focusing on right now to better understand and dig into some of the variation we see there both positive and negative. Okay does one care have a time frame to analyze distribute discuss and develop action plans to address the areas that you outlined that represent greatest areas of improvement are there resources allocated in the 2023 budget to address these improvements the broad question here is sort of what is your next steps for this report and its finding. Thank you for that question it's a little bit of a challenge as so many things are where we are handling you know performance results from 2021 just arriving well right around the corner we will be planning 2024 so managing multiple years at a time having said that we did just receive the data in the last couple of weeks we are still working internally to understand it but our next steps will be to certainly ask follow-up questions of the vendor to more deeply understand the information and then in December and into the new year to be bringing it out through our governance processes for example the committee structure that Dr. Wolfman described bringing it to our board in the context of strategic planning and also incorporating the key information into those HSA consultations that Dr. Wolfman described so I think that's really the first round of dissemination of information then the next step for us is really as we start the planning process for the population health model accountabilities advancement for 2024 which for us begins at the beginning of 2023 all of that information will be incorporated and so for example some of the measures of focused measures or incentive measures might change some of the investments that get discussed with our board that might go into our 2024 budget would be considered over the first six months of next year it is it's a long process you know we're trying to move a dial for a whole state and so it's going to take us some time I think the exciting opportunity in this is to really dig deeper and think about our entire network not only specific segments and how we can bring them together to understand where some of the gaps are and where we want to focus our energy so that we can do really well as a system and not really have fragmented or kind of sporadic focus areas that don't get us the ultimate outcomes that we're looking to see over the next few years. Okay thank you we're excited to look at this report and start digging into it and we look forward to talking with you about it more. I just have one final question shifting gears has one care provided to the Green Mountain Care Board all information on actions investigations or findings involving the ACO or its agents or employees. Yes we have. So with that I'm just going to look to the staff to see if there's any additional questions that came up during the course of the hearing as people are listening to the information I don't see any but I'll just pause for a minute for any hands and seeing none I turn it back to you Mr. Chair. Thank you Ms. Melvett and thank you all for your responses to Ms. Melvett's questions. With that we'll turn it to board questions and we'll try and take our break on time at 1215. I'm new to this role in this field to a large extent so I appreciate you guys explaining all of this. I've heard the phrase mission-oriented organization. What does that mean and do you guys consider yourself a mission-oriented organization? So I'll answer this as Vicki Loner. Yes indeed we do consider our self-emission-oriented organization. We serve our providers to enable them to transform the way that healthcare is delivered by providing them all the things we talked about in our core capabilities through payment reforms that enable them to change the way that care is delivered through waivers through contracts that tie them together. So the short answer is yes we do. And can you explain what one care Vermont's mission is? Yeah I think I actually just did that but I'll reiterate it for you so we as an ACO are working in partnership with our healthcare providers to transform the way that healthcare is paid for and delivered. We do that by helping to support providers and focusing on their healthcare goals and promoting activities through the ACO like actionable both data and innovative payments that serve better outcomes. And our full mission and vision so that's just a summary of it not a word by word can be found on our website and was recently revisited through our strategic planning process in 2021 and came up with that mission vision and values through stakeholder board and staff input. In your view does one care have a role or responsibility to assist or curb healthcare costs in Vermont and improve quality and outcomes? And if so what do you see that role as? Yes we do and our role as we talked through as part of our strategic plan is to really provide those three core capabilities that will enable the care delivery transformation that's needed to be undertaken by the healthcare delivery system. So we provide the infrastructure shared resources the contracting the data analytics to really enter into value-based care services. And if you look at where the federal government is going through their CMMI strategic refresh it's not if people will be or if providers will be in accountable care relationships. CMS is very serious about having providers get paid differently in accountable care relationships into the future. So this is a need that the delivery system has. We offer a venue to be able to leverage those resources without every community having to have their own ACO which would be way more expensive. In your view is one care accountable for curbing healthcare costs in Vermont? Yes we are an accountable care organization. And in your view are healthcare costs in Vermont too high? I would say that nationally healthcare costs are rising and we also have a lot of challenges in our healthcare system right now in terms of access to care workforce issues and others that really complicate the picture. So would you or would you not characterize healthcare costs in Vermont is too high? I would say that affordability is a challenge for many Vermonters. Your website says healthcare costs are too high. Do you disagree with that? No. How do you think one care Vermont is doing at achieving a goal of curbing healthcare costs in Vermont? I would say if you looked at our record year over year in the Medicare program we had exceeded the benchmarks that are being set. And to what do you attribute that? We attribute that to the data and supports that we provide our healthcare providers to have them deliver care differently through value-based care arrangements making them accountable. And what do you think is one care Vermont's most cost-effective tactic to reduce healthcare costs in Vermont? I think that's challenging to say specifically but I would go back again to our core capabilities. The network contracting the data and analytics and the payment reforms are tactics. I understand your tactics. Do you have any sort of hierarchy or basis to a pine on which are the most effective at curbing costs? I don't know that I could answer that question. Do other ACOs assess the cost effectiveness of their strategies? I'm sure they have a way of doing that. Every ACO is different. I would say that overall we're looking at right care, right place, right time, and the total cost of care and the quality metrics. I mean that's the ACO framework. The federal government has sent out a framework for how you measure success in ACO programs and we follow that framework. So how does one care evaluate and assess the various functions to determine how to allocate resources? We do that through our boards and committees. And what do you look at to make that determination? We bring all these through our clinical committees and population health committees and look at the investments that the providers feel will have the biggest opportunity and we also leverage our data as part of that. Is there any sort of cost benefit analysis that's done in connection with evaluating how to deploy your resources? We have not. So how do you verify that where you're putting the money is the right place to put the money? So we're looking at overall controlling utilization, increasing care coordination of services and the primary focus being on primary care. So how do you determine what's the most cost effective way to curb health care costs and to deploy resources to that? And what I'm getting at is I've looked at all your budgets. There's 15 million for population health management. Base 2.5, I think it is for bonus 1.5, a very small amount of money for CPR. And I'm trying to understand if that's the right mix of where you're putting your money and how you determine that. Yeah, recall that CPR is a component of the overall primary care. So you can't just look at that as a separate line item. It would be better to look at our overall investments in primary care that was on one of the slides that we showed to the group. Yeah, thanks. My question was how do you know that the mix you have of the funds and where you're putting them is the right mix? Well, we do have limited funds because recall that our funding is purely through hospitals and the contracts that we have with payers that fund a portion, but not all of those investments. So we have to look at the amount of available revenues that we have coming in compared to our shared savings opportunity to be able to provide enough investments for providers to be able to do the work while recognizing that there's not endless revenues coming in from other sources to the ACO. You're hiring a program evaluator in 2023. Is that right? And what are they to do? Sarah, do you want to take that? Sure. So we are looking to basically become more sophisticated in the structure and type of evaluations that we can perform on individual programs and investments. We have tried over the past few years a variety of analytic approaches and frankly to varying effect in part because of the complexity of the actual work that we're doing, the numbers of interventions out there happening simultaneously, the numbers of organizations that impact them in different ways. And so we don't expect perfection from this individual, but we're really hoping for some advanced guidance to help us think in new ways about how to answer some of those crucial questions. And have you had a program evaluator previously? No, we have not. Is it typical of high performing ACOs to have program evaluators? I don't have an answer to that question. Why had you not employed a program evaluator previously? I would say that it had not coalesced into a clear and apparent need in some of the prior years. We were doing making lots of adjustments, particularly early in the pandemic. We had coming into just prior to the pandemic, a pretty intense focus on new investments and innovations. And we learned a lot of lessons through that process about the difference between, I think, good stated intentions by our network on what we could evaluate, and then some of the practical limitations of data availability, the complexity, etc. And so all of those things started to point us in the direction of wanting to expand some of the expertise that we already had in-house. In connection with the prior efforts that you said were challenging to do this type of work, did you speak with any consultants or other ACOs as to how they do this? We certainly, through the National Association of ACOs, had some awareness and had access to case studies about how others have investigated certain aspects. Frankly, one of the biggest challenges we've seen any time we try to have those conversations with other ACOs is that, by and large, although not exclusively, those ACOs work within a single clinically integrated network, which means they have one EHR data source, they have direct impact on interventions, they can kind of put some parameters around those evaluative activities to make them cleaner and clearer, for us as a statewide network with roughly 170 organizations that Vicki described earlier, it adds many, many layers of complexity. The number of EHRs alone has been incredibly challenging for us as a state, not only one care, but the entire healthcare delivery system is really, at times, stymied by the lack of ability for data sharing and integration that would optimize patient care and streamline some of these efforts. I think it was slide 10, you had a figure of 138 million on population health innovations since 2018. Is that the right amount of money? I think that there's much more opportunity to make investments in primary care and population health services, and that cannot be bore directly and solely from the providers who are trying to make those changes. So, my question is whether or not you think the 138.4 million dollars invested in population health since 2018 is the right amount of money? No, I think that the state and federal government could be investing more money in population health and helping those healthcare providers to make that transition away from fee-for-service to value-based care. And in terms of shifting people to value-based care, it looks like only one payer is actually doing unreconciled fixed perspective payment. Is that right? That is correct. So, how would investing more in population health increase that output? So, I think of the two things as very different. You're talking about fixed predictable payments. So, those are our means for providers to be able to deliver care differently and with more flexibility. That is indeed only being offered by one payer, Medicaid right now. The state doesn't have a means to force commercial payers to enter into fixed arrangements. And through the agreement with the state, Medicare has signaled to the state through that agreement that they will not offer fixed perspective payments. In terms of the population health program, the bonus, which I think was about 2.3-ish million dollars, those payments are tied to other providers achieve certain specific outcomes. Is that right? Yes, there are set of six different measures for primary care, one focus measure for each part of our continuum of care, and then there are targets and stretch goals set either through national benchmarks or where those don't exist through our governance committees. And so then performance is measured against those and payments made. Do we here at the care board have the numerators and the denominators for these metrics? As in what you need to hit to achieve? I don't know if you do or not. I guess I would ask your staff. I believe you do have the measures themselves. And to the extent you don't, that's something we can provide. It's something we're in the process of communicating out with our network right now. Okay, yeah, I'll check with the staff and then we'll get back to you if we need them. They struck me as a good idea and it really could impact change, right?  How are you finding, measuring these and providing payments for achieving them in terms of if it's working? So I think we have some very positive early signals. Recognizing that the PHM program and those six measures will be new starting in January, we have basically built and evolved the programs based on what we've been doing in 2021 and 2022. So specifically, we have right now a value-based incentive fund program, which works very similarly, a set of quality measures, target and stretch goals. Those payments we make quarterly, whereas we'll be making them more frequently under the new model. But ultimately, I think it is working quite well in terms of dealing with one of the biggest challenges that our network had really brought to our attention in the past, which is that if you move the incentive too far away from the expectation for performance, it can become a disincentive or it can water things down. So I think that has improved tremendously. I think the focus of the specific measures and being very clear and crisp on what the gaps are and what the expectations are has been very helpful as well. One of the significant challenges that remains that I think will be a theme over the next few years is that you have to have measures that occur sufficiently frequently at the organizational level so as to be measured and meaningfully able to improve. And you have to have a data source that you can access at large scale. So that really means that we need to do our utmost to rely on claims-based measures, things where we have a large volume of information. In the 2021 and 2022 program, some of the measures selected through our governance process required one care to use manual staff time to continue to gather information from all of these disparate electronic health records. And well ultimately there are times that is important because of the the gap say in performance it's very resource intensive and so we take that into consideration as we're thinking about what are the priorities and what does the network really need to improve on in the future. And would you agree with me that this is a good tactic? I mean to me it seems like the incentive is closely tethered to results and it strikes me as a good tactic. Do you agree with that? Yes I do. We're very excited about it. How did you determine that 2.8 million is the right amount of is 2.3 or 2.5 to 8 whatever it was? How is that the right amount of money for this tactic? Yeah I think there are a couple of realities to to look at. First of all we did not want to have a cliff for providers in our network and move from a program where they had a certain amount of money that they were expecting to receive from one care and the calendar flips to the new year and all of a sudden it goes to zero and they have to earn everything immediately based on incentive because we knew that that would have impacts on workforce staffing their own prioritization of projects and investments. So we decided that we needed a tapered approach and so we arrived at that 85 percent in the base in year one and 15 percent in the incentive as a reasonable threshold and we have socialized through that process and through our governance committees an intention to keep changing that ratio from year to year. The the amount of that change has not been predetermined that will be evaluated each year based on what we're seeing in terms of advancements but ultimately the intention is to shift more and more of it into that incentive payment therefore you know really turning the dial up on making sure that people are being rewarded for achieving those higher outcomes. So there's no table or projections or anything you've communicated about how you see that evolving over time at this point. Tom are you aware of anything that we've communicated out? We've communicated to our board and committees kind of a visual that over time the opportunity for the bonus increases and then the the base payment kind of decreases in a corresponding way and another element being considered is if there's a different integration into the shared savings and shared loss model that would actually supplement this even further and you know over time I think it's important that we continue to put more emphasis on these actual data driven data measured outcomes and there are fewer dollars in the base payments. Why don't we stop there we're two minutes over so we'll take our break down we'll come back at um I think it's one p.m. and unless you guys want to shorten it what's your preference over over there on your side at one care. I think we have one Chair and Poster. Great okay well we'll stick to this again we'll come back at one thank you very much.