Good morning, everyone. My name is Kevin Mullin, Chair of the Green Mountain Care Board, and I'm gonna call today's meeting to order. The first item on the agenda is the Executive Director's Report, Susan Barrett. Good morning, everyone, and good morning, Mr. Chair. A couple of brief announcements. First, we added a meeting for a board meeting for this Friday. As everyone knows, we'll be hearing from the Director of Healthcare Reform for the Agency of Human Services on the Strategic Healthcare Workforce Work Plan today this morning, and we do have a scheduled potential vote, but we may need more time to discuss this, and so we've slotted a meeting for Friday, this Friday, November 12th at 2 p.m. to have a potential vote on the workforce plan. In addition, we have some ongoing public comments. I wanna remind folks about, first, we are accepting public comment through November 25th, 2021, on the 2021 updated Vermont Health Information Exchange Strategic Plan. We would like those comments in by November 25th to be considered by the board and staff, but we accept public comment every day of the year, as everyone knows. In addition, and we'll hear more about this, I'm sure, from our staff this morning, we are accepting public comment on One Care Vermont's ACO FY22 budget, and we're accepting public comment through December 1st in order to be considered by staff for their presentation to the board. Again, we will always accept a public comment, but please try to get those in so that we can consider that as the staff presents information and recommendations to the board. In addition, public comments and minutes to date are located on our website under ongoing special comment periods. And that is all I have to report out. This morning, I'll turn it back to you, Mr. Chair. Thank you, Susan. The next item on the agenda are the minutes of Wednesday, November 3rd. Is there a motion? So moved. Second. It's been moved and seconded to approve the minutes of Wednesday, November 3rd without any additions, deletions, or corrections. Is there any further discussion? If not all in favor of the motion, please signify by saying aye. Aye. Any opposed, signify by saying nay. Let the record show the minutes were approved unanimously. At this point, I'm gonna turn the meeting over to Christina McLaughlin to introduce Ina and Tia up the discussion on the workforce plan. Christina. Thank you, Chair Mullen. Hello, everyone. Good morning. My name is Christina McLaughlin. I'm a health policy analyst here at the Green Mountain Care Board. I just wanted to quickly provide a summary of the board's review process on the draft healthcare workforce strategic plan, which was submitted by Ina Bacchus, Director of Healthcare Reform on October 15th. Act 155 of 2020 directed the board to review and approve the draft plan within 30 days of receipt. And with part of the review process, the board had held two public meetings, the first on October 20th, where the Director of Healthcare Reform presented the draft plan. The board also heard feedback on the draft plan from the board's general advisory committee. The board held a special comment period through November 1st and received and posted public comments to its website and discussed the draft plan and open meeting on November 3rd, providing additional recommendations and feedback and hearing more public comment. All of that feedback and recommendations provided to and from the board have been shared with Ina Bacchus to consider incorporating into an updated plan. So Ina is here today to share the updates made, materials are posted to our website. And as mentioned earlier, the board will potentially vote today or Friday, November 12th at 2pm on the updated plan. So with that, I will now turn it over to Ina Bacchus. Thank you. Thank you, Christina and good morning everyone. Based on the feedback received and the discussions about the healthcare workforce development strategic plan, I would like to share some proposed modifications with you this morning. The first modifications that I'd like to review are with regard to the timing for each of the 40 recommendations that are included in the plan. If it makes sense, I will share my screen to walk you through the document. Make sense. Please let me know if you're able to see the document. It's a word document. We can. If it needs to be, should I enlarge it or is it readable? Okay. As you are familiar, the healthcare workforce strategic plan does contain a number of recommendations. In fact, 40 recommendations across a number of different domains with regard to healthcare workforce development. I am aware that through discussion and through the presentation that was provided on October 20th and the subsequent questions that there was interest in having an understanding of the timeframe for each of the recommended activities. And so you will see that that timeframe is indicated here in this table and these timeframes will be reflected in the modified plan as well. The timeframes I do want to explain are for and to indicate when these activities will start. Not all of these timeframes necessarily, I think at this time it's difficult for them to reflect the full length of time that it may take to complete certain tasks. However, the recommended task we have provided for a timeframe for when those tasks would begin. Establishing interagency partners to work on the implementation of the plan is happening now along with work to plan for integrating with the State Workforce Development Board happening now and likely into early 2022. And I can work through each of these for an explanation. I can also say that the majority of activities are really looking to be underway in 2022. And I do want to highlight a couple of new, well, a change in entities that we would be involved in activities as well as a movement of one activity from a category where it was a future consideration into an active recommendation. So first year recommendations 15 and 16, I have added the UVM College of Nursing and Health Sciences to the lead entities responsible for these activities. The activities are to strengthen incentives for preceptors for all professions and to explore opportunities to expand family practice residency programs. And here in recommendation 18, we have moved the work that we recommended as a future consideration in the initial draft of the report, which was to advance the coordinated approach to promote health careers in K to 12 educational settings. That recommendation, it has been moved to an active recommendation rather than a future consideration and slated to begin work and to be taking place in 2022 and 2023. We also here have added the UVM College of Nursing and Health Sciences as well as employers to the activity, which is to develop and identify strategies to streamline the nursing career ladder and offer advancement to existing healthcare staff. So both again, the College of Nursing and Health Sciences and employers have been added here as key partners and accountable for this work. If you'd like to review the timeframes for each of the recommendations, I am happy to do so. Or we can turn to additional modifications that we have made in the document itself. I can highlight that the most unusual timeframe indicated here for recommendation is the further work to evaluate opportunities to remove barriers to licensure for mental health and substance use disorder treatment professionals. And as specified in the first draft of the strategic plan, the Office of Professional Regulation would undertake this work in a five-year time span. And that is why that is indicated here. Do any board members have questions or comments about the timeline? I don't. I don't either, just an observation that there are still a lot of moving parts here. 40 here, 73 in the report in terms of the number of shoulds. And having a discipline, the leadership, making sure that these things happen according to a schedule, I think is really important. And that's not clear to me here. You have the interagency task force set up with six tentatively or six minimum, there's a minimum of six folks appointed to it and maybe there's more. But I just, this across state government is a huge task and it is gonna need some very crisp and pointed discipline to keep people on task to get us where we need to go. The plan itself is great. I've said that before, it's received great reviews from our advisory board. But the discipline side of this, I think is going to be a struggle and something for the administration, especially to be very cognitive enough. Jess, anything from your end? No, I mean, I understand the moving parts argument. I appreciate all the hard work here and I really appreciated moving that K-12 investment in preparing for healthcare professions up into active priority. I think that's really important. So I'm happy and satisfied. Thank you. So I think, you know, we can move on to the next part. Okay. I will share my screen again, if that's okay with you. That'd be great. Great. And we can see it. Great. Just move to the slideshow view that you, so you can see a larger version. We did receive some feedback through the public comment avenue that asked to reflect the role of the University of Vermont College of Nursing and Health Sciences in the report. And you saw earlier that that role was reflected in the accountability for action on those certain recommendations that I pointed out to you. We've also included verbiage here to reflect the role of the College of Nursing and Health Sciences with regard to the recommended work to strengthen incentives for preceptors for all professions. Further, we received some feedback to ensure that the loan repayment options that we recommend exploring in the report would be applicable for employees in critical access hospitals and to federally qualified health center employees. And that is also reflected here in the recommendation regarding broadening and expanding loan repayment and the work that needs to take place in order to evaluate the opportunities for broadening and expanding and making recommendations based on that evaluation for where the best opportunity lies in an expanded program. As a part of that evaluation and exploration, we offer here this language for consideration so that any work would adequately consider how critical access hospitals and employees of FQHCs could be included. So, you know, before you go to the next slide, one of the questions I had and it came up when looking at your timeline. So we know, for example, that the precepting nursing students is a problem at more than just UVM. And, you know, we have other colleges in the state with nursing programs. And I saw that it looked like you had UVM College of Nursing as the lead agent. And I just wanna make sure that the others won't get left behind because I think it's a problem at more than just UVM. Absolutely, and I can return to that document. I think I may have highlighted the addition of the College of Nursing and Health Sciences, whereas formerly we had indicated perhaps lead for the state colleges and we didn't want to leave the College of Nursing and Health Sciences out of that. As long as everybody's in, then I'm happy. I will double check to make sure that that is the case. Further changes that we are proposing for the report based on feedback would be to include nursing faculty and include nursing faculty when considering scholarship and loan repayment programs, meaning whether, I took this feedback to mean whether or not nursing faculty could be recipients in these programs. And so here we've indicated that any, that the work to broaden and expand loan repayment should include exploration and an evaluation of any opportunities to also include nursing faculty in these programs. Those recommendations are reflected here in the highlighted yellow text in two of the report recommendations, the recommendations considering loan repayment and the recommendations for exploring opportunities to increase scholarship funding. And finally, while the report was clear that direct support professionals had not been the focus of the advisory group and the advisory group had focused in the area of primary care nursing, dental and mental health care. We did want to add some additional activities here to recognize the particular challenges for the direct support professional workforce. And so have modified the recommendation to assess barriers for the recruitment and retention of the non-license workforce. We've modified the recommendation so that training needs and career advancement opportunities may also be considered and that this work would be considered through the avenue of ARPA funding, which includes home and community-based service funding offered through the 10% Medicaid F-MAP bump for home and community-based services. Okay, so do board members have any questions for Ina on the proposed changes? I have a couple of questions. I was wondering if you could just briefly talk about any feedback that you decided was not appropriate to incorporate and why you didn't prioritize that. It's already, you have a lot of recommendations in here, so I certainly understand that, but if you could just briefly speak to that, that would be helpful. We did, there was a consistent feedback with respect to the issue of preceptors, the availability of clinical staff for providing clinical training and issues related to the availability of educators for the nursing workforce in particular. And that feedback was very important. It acknowledges one of the key issues that we found in this work, which is that there are some barriers with the current system in regards to the number of clinical placement opportunities that are available, and that limits how much of a nursing workforce the state we can kind of generate within the state of Vermont. Again, those are very high priority issues, and I believe are reflected in the working group that is going to be put together and led in part by the Office of Professional Regulation to understand a number of issues related to the availability of clinical placements. And so that working group is pretty encompassing. It's a high priority task and I think addresses some of that feedback that we, well, the working group activities largely address that additional category of feedback that we received. Thank you. Other questions for comments from the board? I had one of their questions, Kevin, which is, you know, what are you thinking, how frequently are you thinking the interagency task force would be meeting, at least initially? I can't speak to a set schedule, but there is active work going on already with, you know, regular meetings and what I would consider to be subcommittee meetings with branches of the task team having active spin-off meetings with one another now. Okay. So I think one of the things I would like to see in our approval is a requirement to have periodic report backs about how the work is going because to Tom's point, it's a lot of tasks and a lot of different people. So I think having a better understanding of who's on first and how the work is flowing over time will be helpful. And quite frankly, I think could help provide some to Tom's earlier point about accountability and keeping things on track, could help the wide vast of people who will have to be working kind of understand that they need to prioritize the issue within a certain cadence. So I wanted to throw that out there. And then the other thing that I would like to see at some point is a report back up with a prioritizations in terms of 40 recommendations even with a bunch of different people leading on them is gonna be tough to pull off. That's just a lot of recommendations. So I think in order to be successful, it would be important to prioritize the highest priorities and make sure that those are highlighted because many of these things will be competing for short resources.  So that's really more a comment about what I'm thinking about in terms of when we move to a discussion and vote. Other board members? Just a quick follow up to Robin's comment. I mean, I know that the state is in the middle of, although it's not out there in the public, it was the middle of putting together the fiscal 23 budget. And those things are usually kept under wraps until the governor's budget addressed sometime in late January or February. So I'm just wondering what you're thinking might be about that. Should we assume that we need to wait until the middle of January to find out how the governor's recommended budget is lining up against these action items or will there be a way for us to have a sneak peek or something or at least some kind of flag system that says going well, not going well, because it's a long time between now and late January. And just to follow up, Ina, on Robin's point that I think what Robin is asking for is basically an update from whoever's leading the task force and at this point it's you. And that's what we would be looking for. We wouldn't be looking to bring the whole task force into board meetings, but would like to get regular updates from the leadership. Happy to provide those updates, yes. And I do appreciate board member Palom's comment as there is certainly consideration for the work that goes into developing the budget. And he is familiar with what that process entails and how it works. And so that will be an element until the time at which the budget is presented. Yeah, I didn't think you were gonna let loose on any, anything in advance. Jess, did you have anything? No, I would just, I support Robin's suggestions for updates from Ina and also a prioritization of tasks. But in general, I'm supportive of the new draft or the new final strategic workforce plan. And I appreciate all the hard work that's been done to put this together. And maybe we'll get some federal dollars that may help in some of this regard. So anything else from board members? If not, I'm gonna open it up for public comment. Does any member of the public wish to comment on the presentation from Ina Bacchus, Director of Healthcare Reform? I'm not seeing any hands raised and I'm not hearing anyone. So Ina, as mentioned previously, we'll be taking this up for a vote on Friday at two o'clock. Thank you. Thank you. Thank you for your time this morning. So at this point, I'm gonna check. Joanne, are you on? Yes, thank you. I'm here and ready to go. Okay, super. So I'm going to turn the meeting over to Marissa and Sarah to tee up the OneCare Vermont budget presentation. And once they've teed it up, I'll ask Joanne to square in anyone from OneCare who is going to testify. So Marissa, Sarah. Thank you, Mr. Chair. For the record, this is Sarah Kingsler, GMCB Director of Health Systems Policy and I'm joined by Marissa Melamed Associate Director of Health Systems Policy and I'm glad you said... Hold on. Sarah, hold on. Hold on, Sarah. This is Joanne, the reporter number one. I can't hear you and please speak slower. Sure. Louder and slower. Is this a little bit better? Yes. A little better. Sorry about this. Try switching the headphones. Any improvement there? Great. Yes. Thank you. All right. There we go. All right. Thank you again. For the record, this is Sarah Kingsler, GMCB Director of Health Systems Policy and I'm joined by Marissa Melamed Associate Director of Health Systems Policy and we will do a quick staff introduction to remind the board and members of the public of the process for the board's review of OneCare Vermont's budget and to provide a little bit of context before we hand it over to OneCare. As the board knows, there are two components of GMCB's oversight of accountable care organizations or ACOs. First, certification, which occurs once following an ACO's application and eligibility is verified annually. I'll note that this applies only to ACO seeking contracts with Medicaid or commercial payers, so not Medicare-only ACOs. Secondly, budget review, which generally occurs annually in the fall prior to the start of the ACO program year, noting that an ACO returns in the spring when payer contracts and attribution are finalized to present a final budget. I'm sorry, I'm losing you. Please slow down. I lost it. Start it secondly, please. Sure. Secondly, budget review, which generally occurs annually in the fall prior to the start of the ACO program year, noting that an ACO returns in the spring when payer contracts and attribution are finalized to present a final budget. Marissa's on mute. Thank you, Sarah, and thank you, Mr. Chair. Next, this slide is an overview of the timeline of the process. We are here at November 10th, which is the hearing. And as a reminder, like Susan said at the beginning, we do accept public comment on the ACO budget submission and hearing in all materials throughout the process. However, we request if you would like us to be able to consider your comments prior to our staff analysis on December 8th to please submit comments by December 1st. The board will then consider the presentation from OneCare and the staff analysis and recommendations and tentatively vote toward the end of December. There'll be another opportunity, of course, to submit public comment prior to the final presentation and vote from the staff. We finalize a budget order early in the new year. And then as a reminder, this is a two-part process, really. The prepared budget is reviewed and approved in the October to December period. However, payer contracts are not finalized until potentially the end of the year or after we're almost through or through this budget process. So we have OneCare prepare or revise budget based on their finalized contracts and come back and present that to the board for review against the approved budget sometime in the spring. And then, of course, there's ongoing monitoring and reporting as part of the oversight process throughout the year. As a reminder in your review of the budget and certification, the board must consider Green Mountain Care Board rule five, specifically section 5.405 in deciding whether to approve or modify the proposed budget of an ACO projected to have 10,000 or more attributed lives in Vermont during the next budget year. The board will take into consideration any benchmarks established under section 5.402 of this rule, the 16 criteria that are listed in 18 BSA, section 93, 82, B1, the elements of the ACO's payer-specific programs and any applicable requirements of 18 BSA, 9551. This relates to the Vermont All-Payer Accountable Care Organization Model Agreement for the state and Vermont NCMS, sorry, between the state and NCMS. Any other issues also may be considered at the discretion of the board. We also consider public hearing and comments and participation by the Office of the Healthcare Advocate. There are, so the 16 statutory criteria in 93, 82, many of these, as I mentioned, relate to the strategy underlying the All-Payer Model. As a reference, they're provided at the end of the slide deck so you can read through them. But for example, to summarize the criteria requires the board to consider the effects of care models on appropriate utilization, the character competence, fiscal responsibility and soundness of the ACO and its principles, efforts to integrate with a blueprint for health and community-based providers, incentives for systematic healthcare investments in primary care, the social determinants of health and preventing and addressing adverse childhood events, ACO administrative costs, the effect, if any, on Medicaid reimbursement rates on the rate for other payers and the extent to which the ACO makes its costs transparent and easy to understand. And that last one I think is a big part of what we do today at the hearing, which is allowed the public to hear from one care and describe how their model works. And again, the full criteria are provided at the end of the slide deck for your reference. I'm gonna turn it over to Sarah for a quick word about the all-pair model targets, which are also part of your consideration in this review. Thank you, Marissa. So as Marissa noted, number three on the prior slide says that we need to consider the all-pair model agreement requirements. And so we've lifted the targets that are embedded in that agreement here. First, total cost of care, the agreement sets a cost growth target that is in line with Vermont's historical economic growth. Secondly, there are quality and population health outcomes targets embedded in the agreement and they all kind of line up to three high-level goals. First, increasing access to primary care. Second, reducing deaths due to suicide and drug overdose. And third, lowering the prevalence of chronic disease. Finally, the agreement includes targets for scale. And I just want to note that Vermont received a letter from our federal partners in October, recognizing that the agreement scale targets were not attainable based on information that was not available when the agreement was signed and waiving scale enforcement for the remainder of the current agreement. That letter is posted to our website and the board will continue to produce reports on scale performance. That will still be something that we track, but we will not be held to that standard. Marissa, you're on mute. My apologies. Finally, the ACO 2022 Budget Guidance Summary is here on this slide. This is the outline of the guidance that the ACO was required to follow when they submitted their materials. So for your review, you will hear information, background information, information on provider networks, payer programs, total cost of care, risk management, their budget details, the care model, quality and population health, community integration, information, and any information related to the all payer ACO model that may be relevant. And in addition, the guidance includes information about ACO budget targets, the revised budget process, as I mentioned, and the yearly monitoring. So the agenda for today, you heard from Sarah and I with the staff introduction. One care will have about up to an hour and a half if they need it for their budget presentation. We will have some questions from the Green Mountain Care Board staff. Then we will turn it over to board questions. There will be a potential break if needed for executive session, and that will be explained if necessary. We will break for lunch or bio breaks as necessary at the discretion of the chair. Continue board questions if needed. The health care advocate has an opportunity to ask questions and then we will have public comment at the conclusion of the meeting. So it is expected to go to stop for lunch and continue afterwards. And that concludes our staff remarks. Thank you. Thank you very much, Sarah. And thank you very much, Marissa. At this point, Vicki, if you could introduce all members of your team that will be testifying today and I'll ask Joanne to swear you all in as a group. Yeah, thank you, Chair Mullen. And I'm gonna do my best for my voice, but I do have a bit of a cold. So it might not be as strong as usual. So for the record, Vicki Loner, Chief Executive Officer, One Care Vermont. We also have with us today, Sarah Berry, Chief Operating Officer, One Care Vermont. Tom Boreys, who is our Vice President of Finance. And Dr. Kerry Wolfman, who is our Chief Medical Officer. And running our slides for us is Ginger Irish, who is our strategist at One Care Vermont. Joanne, if you could swear everyone in. Sure, would everyone please raise their right hands? And do you swear the testimony you're about to give will be the truth, the whole truth and nothing but the truth, so I'll help you, God. Yes. Yes. Thank you. Okay, so whenever you're ready to proceed with your presentation, proceed. Great, Ginger, can you tee us up? Thank you. So I just wanna thank the committee for taking the time today. We have a fairly robust presentation that we hope to get through in 90 minutes or less and leave time for some questions. Next slide, please, Ginger. Next slide. So for background, for those of you who might be new to this testimony from One Care Vermont, One Care is an ACO operating in the state of Vermont. We contract with thousands of Vermont healthcare providers and hundreds of organization with a shared goal of improving the health of Vermonters while slowing the cost of growth. And we collectively believe as a group partnering together that the best way to really accomplish this is through shifting away from the current fee per service system to a value-based care system. That really rewards providers for taking better care of their patients and for the outcomes. Transitioning to value-based care, it really does take a village. It takes the providers, the ACO, the Green Mountain Care Board, the legislature and the state to move collectively in this direction because it really is a seismic shift in the way that we are paying for and delivering healthcare. With that said, today's presentation will be solely focused on what One Care is doing to really make that shift to value-based care and how the budget supports it. So I want to start off with the growing statewide attribution. And really this is obtained by being able to contract and having an engaged provider network that truly believes in value-based care. Right now we're over 5,000 providers strong and I just want to take a second to sink in because that's a lot of providers growing in the same direction with a common vision. And so that's something that we as a state should be very, very proud of. I haven't seen this sort of provider networks from different organizations in any other country that are moving together towards value-based care. We have over 90% of eligible primary care in this model too because the foundation of this is really to support primary care. I also want to point out that we are really looking to make sure that all of our programs are supporting the delivery system by enabling them with population health investments. And through one care, we are able to directly invest in the providers who are serving Vermonters $28.9 million directly for care coordination, quality improvement, things like advance comprehensive payment reform for independent primary care. And that funding would be gone absent the ACO and the participation around the state. So that's a really important note that this work takes investment in the delivery system and that's what's available through the ACO. Also really important in supporting this delivery system transformation, you really need to shift away from a fee-for-service construct where providers are incentivized by doing more services and not necessarily rewarded for being innovative in the services that they do in a way that is more patient focused. So one care has been able to develop and implement very comprehensive payment reform programs. Right now, we're looking at about $1.3 billion of existing, so that's not new money into the system. That's existing healthcare dollars, half of Vermont's eligible healthcare spend from the latest data I saw from the Greenmount Care Board that is being shifted away from a fee-for-service construct into value-based care. And under our current agreement, 100% of that is in advanced payment models. Gender, next slide, please. I think the important thing to not lose sight of is that Vermont is not alone in this goal to improve care and slow the rate of cost growth by shifting to value-based care arrangements. CMMI, which is an arm of CMS that you all know very well, put out a white paper to look at what they were trying to accomplish over the next 10 years. And their goal is to hide every Medicare beneficiary in an accountable care relationship by 2030. So that's moving every Medicare beneficiary out of a fee-for-service construct into one that looks at value and cost of care. So putting the accountability in the hands of the providers. This is a fairly lofty goal, and it really can only be accomplished if, as I said earlier, if you really had your whole system of care moving in this direction, and that's what was contemplated under the all-pay-our-model agreement was to have that public-private partnership where all kind of oars were moving in the same direction. I believe in Vermont that we have a good opportunity based on the model design that we have to meet this lofty goal. If you look at the current national statistics, about 42% of Medicare beneficiaries, and this would include Vermont, are in an accountable care relationship compared to Vermont where we're already ahead of this curve with 47% of Vermonters in an accountable care relationship. And what I really wanna point out here is that this is hard work, and also I don't think I have to tell anybody on this screen today that it's only been made harder because of the pandemic and the stress that has been put on our healthcare workforce and our system today. But yet, they are so committed to this work that we have not lost ground over the last couple of years. We've continued to engage providers. We've not lost momentum in that way. We continue to successfully implement value-based care contracts, and you'll see that there's growing number of providers in our independent program. And we continue to deliver on the necessary infrastructure that's needed on a statewide level to really support providers in making this transition. Next slide, Ginger. You all had a presentation just last Friday by Norck out of the University of Chicago. And I think this was a really important study looking at the first couple of years of both Vermont's all-payer model and the impact that the ACO is having. And the thing that I wanna point out on this model that I believe you did a good job at last week is that this is an independent evaluation. It's really using a robust qualitative and quantitative analysis on whether or not this type of model will bear fruit and make progress. And it is indeed showing that we are moving in the right direction as a state and through the ACO with statistically significant Medicare gross spending reductions and reductions in things like acute care stays and 30-day readmission. This really positive report coupled with the work that we did as an ACO with our provider partners earlier this year to really look at who we were as an organization and what work that we should be doing has really put us in a better position to understand both our strengths and the opportunities and to be able for us to examine using a national framework. What kind of steps do we need to be able to take as an ACO to assure our success and sustainability into the future? Next slide, Ginger. Out of that strategic planning process, we had to really look at who one care was, what we represent and what we do. And one of the things that would seem obvious, but it really became obvious and kind of striking through the process is that we as an ACO are very unique in that we are not one organization. We are hundreds of organizations over 5,000 different providers and thinking about how that uniqueness and what strengths that brings with us and then also what challenges it might bring with us as well. Because obviously having that many organizations coming together with a common purpose, not all organizations are going to have the same needs, resources and strengths. So thinking about what we as an ACO really needed to be able to provide the collective whole so that they could be successful in this journey. I think this board understands as those many providers in Vermont that you can't be all things to all people. So you really have to think about what your core focus areas are going to be and what are the expectations and supports that would be provided through an ACO. So that's how we landed on these core capabilities through the strategic planning process and working under a national framework of what would make an ACO successful to do this work. The first one is network performance management and that's not completely obvious at first blush what exactly that means. That's really the contracting arm of the ACO and bringing and engaging providers together to work under a common framework, setting expectations around accountability to make sure that we're all working together towards a common goal. And as you will see in this budget we continue to deliver on that engagement and contracting through multiple providers within Vermont and through multiple public and private payers. The next thing that's really important for us to be able to do at the ACO is to provide that data and analytics directly to healthcare providers to give them insights on where the strength and opportunities are and how they can deliver on improved outcomes for their patient populations. And then there's that supportive payment reform behind it. What kind of payment structure is needed to provide predictability and flexibility to providers to really be able to deliver on that patient centered medical care. And so with that I wanted to formally introduce once again but in a little bit more detail Dr. Carrie Wolfman who is our brand new CMO. Carrie has been an innovator in healthcare delivery reform for years ever since the ACO's inception. She is also a very dedicated primary care practitioner actively practicing and branding. And I think it's really important to understand from a provider's perspective why these capabilities that are offered to the ACO are important to physicians like Carrie and to her patients. And so with that I'm gonna turn it over to Dr. Carrie Wolfman. Thank you. Good morning. Thank you Vicki for that introduction. I'm really feeling honored to be in this position working with the one care team to keep pushing ahead towards our goals for high value care. Next slide please. All of us know that the COVID-19 pandemic has brought unprecedented strain on the healthcare system at large. Patients providers and systems have all had to adjust in ways we never had imagined. And Vermont has not been spared from the impacts of the pandemic. We continue to see and read about the grip that this infection has on our state and on our country. Innovation has been required and is paramount in order to take care of healthcare business. In both primary and specialty care, inpatient and outpatient worlds, we've had to adopt new workflows and embrace new ways of managing such as telehealth appointments, staggered in-person appointments and increased patient portal messaging to give a few examples. There are many other ways we've had to adapt. I'm also surprised at the resilience and willingness of my patients to seek access in new ways. And in fact, many of them seem to feel even more in charge of their own health, at least in some ways, with their ability to perform home blood pressure monitoring, improved glucose monitoring, symptom monitoring and reporting. More innovation is needed, such as e-consults with specialists in order to enhance access. As we continue to see the effects of delayed care and backed up schedules, as well as staffing shortages. As a primary care provider, I see ACO efforts and programs as a vehicle to move forward. For example, you will hear later about our comprehensive payment reform program, or CPR, which is a fixed payment program that supported 11 of Vermont's primary care practices when fee-for-service fell off during the pandemic. And we believe that care coordination is at the center of ACO success. This was true actually before the pandemic, but is brought to bear even more dramatically now with growing stress, distress, and lapses in care of all kinds. The care coordination platform supported by OneCare is evolving this year, in collaboration with our members. What we know for certain is that if Vermont's population lacks housing, food, transportation, emotional and mental safety, and access to healthcare, overall health is at high risk. Assessing and then addressing the social determinants of health requires a team, resources, and solid data and analytics to help guide processes. I believe we have abundant opportunities for improved collaboration. We've made great strides partly due to the pandemic in collaborating and communicating across all of the healthcare spectrum and throughout our communities. The team at OneCare is committed to making connections and seeking feedback from our stakeholders, including our members who are both independent and UVM affiliated. The general public, patients, our payers, our state and government partners, including you, the Green Mountain Care Board. We need to work together if we want Vermont's population to experience life with less illness and greater access to all the components that lead to health. And now I'd like to hand this over to Sarah Barry, the COO of OneCare Vermont. Good morning and thank you for the introduction, Carrie. Next slide, please, Ginger. So in this section, Dr. Wolfman and I are going to walk through some of the highlights and advancements that we're making here as an ACO as a collective group of primary care and specialty care providers, continuum of care providers across the state. And within these collective goals, we are really focused on how, as a network, we can improve the quality of care, appropriate utilization of services and cost of care. So in this section, we're going to use the framework of the core capabilities that Vicki introduced moments ago to focus our remarks and we'll end by sharing some lessons learned, particularly over the course of this last year and through some of the processes of gathering feedback that Carrie just described. I do want to pause though and note that this may seem a little out of order. We are referencing this as budget section seven to keep everyone well grounded in the narrative and how we are aligning with the budget template. But in this, we're taking the opportunity really to set the stage and reflect upon all of the work that has been accomplished over the last year, the changes that have been made coming out of the strategic planning process and really looking to the future, how we're setting up the ACO to continue success and growth and evolution in 2022 and beyond. Next slide, please. So to begin, the first core capability of network performance management really encompasses three critical components of ACO performance. First, we serve as a hub and a connector organization bringing together this diverse network of providers through annual contracting processes, as Vicki described earlier. I think it's critically important to recognize that these organizations are voluntarily participating in this model because they believe in the concept of value-based care and this belief has not wavered. We continue to have a very large and diverse network that is statewide with more than 5,000 providers supporting almost 300,000 attributed lives. And we took a pause and looked at how many organizations this represents in the function of how we contract across payers and with our network. And today we have more than 160 different organizations that are supporting these payment reform and care delivery transformation processes. The next key element within network performance management is really the quality of care and making sure that as a network, we are focused on providing the highest quality care to all of the patients that seek services throughout the state. In a moment, I'll discuss a bit more about how we focused our network on key quality metrics over the past year and worked to align incentives based on their feedback. But first, I do wanna acknowledge that the pandemic continues to impact quality of care as people delayed care and we will have some ground to regain in this area over the next few years. Finally, within network performance management, it encompasses our care model and this includes well-care, preventive care, as well as acute care with a significant emphasis as you'll hear on activities to improve coordination and collaboration across the local community and the broader system of care. So in a moment, we'll share a bit more about how we've been evolving programs within our care model to continue to optimize both care delivery and focus on achieving the outcomes that we all want to see for Vermonters. Next slide, please. So now I wanna take a closer look at our quality program which we call our value-based incentive fund. As I mentioned, we've been working hard to align our focus and incentivize providers around a small list of key areas to help alleviate providers feeling like there are too many priorities and when there are too many priorities, none are truly priorities, right? So our population health strategy committee is through a process of reviewing and reflecting upon key data that one care was able to provide and gathering feedback and perspectives within local communities, selected four key measures, two for adults, focusing on individuals with hypertension and individuals with diabetes, well as some who may have both and two for children and adolescents, depression screening and follow-up and developmental screening in the first three years of life. These were selected because they really represented areas where there was opportunity to improve, both geographically, so across our state as well as when we look from one program of say commercial to a Medicare population that really across the board, there could be some deep engagement and thinking about where there are opportunities to provide the highest quality care for these populations. So in response as part of this discussion of focusing down on these selected measures, we heard very clearly from our primary care providers in particular that they needed more access to timely and specific data, data that was not just aggregated within their local community, but really what was happening for their patients and a number of cases that was information that was not otherwise accessible to them, certainly not on the frequency with which they wanted to see it. So as a result, one care reallocated staffing and has worked to advance our claims and clinical information. And we've really supplemented it by having several staff members manually abstract data from electronic health records over the course of this year in order to get enough information and that timely information to inform real-time performance monitoring and change focused at the local level. So as you'll see on this slide, there are 54 separate organizations that are receiving quarterly performance data and coaching support to review and understand the information they're receiving and to identify ways that they can change workflows, they can partner within their care teams and across organizations in their local communities to improve performance in these areas. The table on the bottom of the slide is a snapshot of the first quarter of this performance year of 2021, looking at briefly just an example of an organization here abbreviated as a TIN and also a health service area. And obviously this is a much longer report, but what this does is it shows you for the organization and for the health service area in which they organize and support patients, what does performance look like in each of these four domains? And did they meet the target? Did they meet the stretch goal? And so I think one of the things that's important here is if you look at the bottom row of this table, again, recalling this is the first quarter of the year, when you aggregate up and you look at the ACO level information, you'll see that as of the end of the first quarter of 2021, as a network, we were performing below target in hypertension. We met target for diabetes and depression and we were actually a bit ahead of our stretch goal for developmental screening. So the question may arise, well, then how does this provide a signal for providers? And I think what's important is that we recognize that unlike data that are collected annually, that aligned with ACO payer contracts and are really used for kind of a judgment or an accountability framework, this is really intended to be small scale, rapid snapshots of data collected to inform quality improvement processes. So as such, the numbers, the number of individuals that were sampled to collect this information varies and in some cases is quite small. And so it's really intended not to make judgments again, but to provide those signals to say, okay, if I'm a care team coming together to reflect upon how I'm supporting patients who have hypertension, am I seeing unexpected variation? How might we think about this from a population perspective and create some different prompts or workflows or processes to help support person-centered care and attainment of say better management of hypertension? And so in order to advance this program and this focus that we've described, we've also aligned funding and we have over $2 million of incentives that come from hospital funding sources that support action through meeting and exceeding these targets and stretch goals. And so that funding is distributed throughout the year rather than in past processes where any incentive funding would have come say as much as 18 months after activities had started. So again, receiving some pretty significant positive feedback from our provider community both about receiving more timely data and information and also about aligning the incentives in a more timely manner. Next slide please, Ginger. So in this slide, you can see a de-identified example of a new transparent data reporting tool. This is specifically aimed at primary care practices that are working through those focused value-based incentive fund measures. This report is in addition to the specific data that they receive about their individual performance on those target and stretch goals. And what it does is it uses a simple stoplight approach to benchmark performance against one another and ideally create some energy for practices to connect around opportunities to improve. So for example, if I were in a practice where I saw I had signals that were red or yellow and I had some colleagues either in my community or in another part of the state that their performance looked green, one care could help facilitate some outreach and connection to identify what are some of the processes and systems that that practice that's performing so highly has in place and how might I learn from that? This is in beta testing right now, we've received some very positive feedback and we're going to be rolling out the live report very shortly. Next slide please. So now with respect to our care model, we've engaged quite deeply with our network to gather feedback and involve our care coordination program as part of an ongoing learning system. This started just after this time last fall and when we surveyed over 120 care coordination staff out in the field providing services and asked them about what was working, what needs they had, the barriers they were experiencing. And as a result of that first survey, we really focused some activities and took action around beginning a process to evaluate the shared care communication platform called Care Navigator. They asked for and we conducted specific educational sessions, particularly around motivational interviewing and we worked to develop with them an education plan. One of the reflections that I think won't surprise you particularly given the conversation earlier this morning is that the workforce challenges are tremendous and that includes for care coordinators across the state. And so one of the ways that one care has been able to be helpful in that space is that as workforce turnover has occurred, we have been there to provide training and support to facilitate skill development of new care coordinators as well as to support advancement of care coordinator skills. And we do that through in part our e-learning platform through one-on-one interactions and certainly through a group educational sessions as appropriate. That was just the first of several mechanisms we used to gather feedback. We also have considered the feedback and recommendations in the state's all payer model improvement plan and we gather tremendous stakeholder feedback from our strategic planning process that took place over the winter and early spring. And through those conversations, it became clear that we needed to engage more deeply with our network through a series of focus groups and listening sessions that occurred over the summer. So just over the last few months. And during those sessions, we really focused on reflecting and gathering feedback on the core principles of one care's care coordination program, the payment model itself, what was working, what wasn't working around that, the tools and resources, whether it be the communication platforms, the way that data and information and reports are shared, the educational supports, all of those things were on the table for discussion. And I just wanna stop and say, this was an incredibly deep and reflective process that took place. I think that it's something that we've, while we've used it in the past, it's something that I think you'll see more of from us in the future. And in the end, through these conversations, I'm really pleased to say that we confirmed all of the core components of our care coordination program, including the centrality of person-centered care, shared care plans as tools, team-based care concepts that extend throughout the continuum of care, the value of lead care coordinators, particularly those that the individual selects, I like to call the quarterback of their care team. The use of care conferences is a facilitative tool to help communicate about goal setting and goal establishment, as well as the barriers that may need to be addressed or that arise. And so that was, I think, a really strong foundation then to move forward from. The next thing that became very apparent in those conversations is that there really was an opportunity to separate out the payments that OneCare provides to our network from the documentation in the shared communication platform, Care Navigator. And this was really a strong request from our network to work towards simplifying the program and reducing the burdens for providers. So as a result, through many rounds of feedback and kind of iterative learning, we designed for 2022 a payment model for the care coordination program that relies on a base payment for network accountabilities and an incentive component based on performance. So you'll see from the little chart in the bottom right that in 22, the ratio is set at 85% of the total. We'll go out in base payments and 15% will be aligned with incentives. However, I do wanna note that we anticipate this ratio will be adjusted over time with a higher proportion moving into the incentive component. And that's because it really needs to align with our desire to achieve measurable and consistent outcomes for individuals served in this program. So we'll be working over the next months and through the spring with our network to define kind of what that stair step approach will look like. But that is clearly the intention and something that our provider network felt like made sense and could provide them with both the resources they need to maintain the care coordination services that they're providing as well as a view of the future to help them plan from their business perspectives. Next slide, please. So diving a little bit more deeply into the care coordination program, one of the new strategies our network has engaged in this year is utilizing some new, what we call sub-population reports that OneCare has provided. And the intention of these reports is to really help focus and prioritize outreach and engagement. If there is a list say that a care coordinator receives with hundreds of names of individuals that might from a data-driven perspective indicate that they could potentially benefit from this program, sometimes that can be overwhelming to figure out where to start. And so what we've done is provided these narrower lists as well to say, well, one of the places you could start is you could look for individuals that have frequently engaged with the emergency department and reach out and have some conversations about how we might be able to more appropriately serve their needs in another setting of care. We can make sure that they have an established and trusting relationship with primary care that they can break down some of the barriers that might exist around, say, timing or transportation, for example. A second sub-population is really looking at those individuals that have frequent inpatient hospitalizations. So where are there opportunities, again, that we might be able to create processes to support individuals before they get sick enough that they need to use acute care services. And then also looking at individuals who have high medical, mental health, and or social needs. Again, key indicators when we look at opportunities to better support for monitors and to facilitate high quality coordination of care. So in this setting, I also think it's important to recognize that despite the pandemic and changes in utilization that we've seen, we've continued to see high engagement in our care coordination program, we have more than 4,000 individuals in active care management right now and several thousand more in early stages of engagement. To support the ongoing evaluation of our care coordination program, we continue to focus on key process and outcome metrics as we have in the past. However, we're also working with our network to collect the key data points in a simpler fashion. Again, this is in response to feedback about how we can reduce the burden associated with the process. And so we are in the process of working with our network right now and some educational opportunities, providing some communication to make sure that they're ready for these changes that will go into effect in January. Now I'm gonna turn it over to Carrie to share a bit more about the program specifics for 2022. Next slide, please. To summarize One Cares Accountabilities for 2022 in what we are calling this first core capability network performance management. We will continue to push patient panel reviews, management and outreach. This will help us identify patients on panels where access is lacking. There are lapses in care, both preventative and in management of chronic disease. And you keep hearing the term team-based care. This is part of team-based care. We will invest time and resources to redesign our care coordination platform as Sarah just explained and the reporting that comes out of that. We will require our members to participate in biannual attestation for care management and to incorporate professional development for their care coordinators. We plan to expand our cross organizational connections, collaboration and communication, starting with a look at our committee structure to ensure inclusivity and focused work. We hold ourselves and our members accountable for ongoing process improvement, which is essential if we aim to improve quality and health equity and to reduce costs. And now I'll hand it back to Sarah to talk about our second core capability, data and analytics. Thank you, Carrie. So as Carrie mentioned, as we dive into data and analytics, we're really focusing on how we can provide actionable data and insights for the providers across our network. And similar to what I was describing a moment ago in terms of seeking feedback from our network, in this arena, we distributed a survey and found that three quarters of respondents were currently using data provided by OneCare to perform some pretty key functions within and across their organizations. First of all, they were using it to make informed financial decisions. They are using it to facilitate their quality improvement activities, informing them around where there are opportunities, as well as again, where there could be collaboration or new connections built. They're refining workflows. This really gets back to some of the panel management opportunities that Carrie described a moment ago. And they're importantly communicating and coordinating services and care across their communities. Finally, many reported that they were using it to identify variations in care and quality. At the same time, providers also asked them to meet them where they are currently at in their data journey and that they needed more variety of supports from OneCare. So we are responding to this feedback, both with some new focused reporting, but also with increased access to analysts for at-elbow support. So at this point, we have assigned individual analysts into each of our health service areas with some priorities for outreach and to really help facilitate deeper connection and deeper understanding about the data so that it truly is providing those insights, not just information. So now what I'd like to do is share with you a couple of brand new reports that our team has been developing so that you can see how we're responding to these requests. Next slide, please. So first, here's a snapshot of a new financial performance report that we rolled out earlier this summer. This report brings critical information together in one place and communicates new year-end forecasted financial performance. I think an important component of this report is that it moves through the system, starting at aggregate, kind of the macro-level ACO results down to a local community, a health service area indicators of performance, and then lands at practice-level financial outcomes. So while you'll see this is just a representation of this report, we've now been distributing it for four months now, receiving very positive feedback. And again, providing us some new opportunities to support this process through enhanced education, providing some explanations and training about how not only to interpret the information here, but really how to utilize it most effectively. Next slide, please. So this is a new report for primary care, we call a panel report, and it's in beta testing right now, so we have not fully distributed. This report is focused similarly to the financial report, but this one is about bringing critical cost utilization and quality data down to the practice level with panel information provided all in one place so that you really get a comprehensive snapshot of what is going on, say, in an individual practice. The other thing that I think is really a great opportunity provided through this new report is that it provides benchmarking against a group of similar practices. So for example, if I work in a federally qualified health center, one of the data points I now have accessible is, well, how does my performance relate to other federally qualified health centers around the state? As I mentioned, this one is still in the final stages of design, and we will be moving it forward very shortly. And so we're looking forward to that. Hopefully what you're seeing through some of the examples I'm providing is that we've really focused in a lot on making sure that primary care as the foundation of so much of our model has the information that they need, both at the local level, so within their organization, but also kind of environmentally in the broader context of then what that looks like in terms of opportunities to benchmark locally and across the state. So now I'm gonna turn it over to Carrie for a few comments. Sarah just showed two types of reports that are examples of what our providers are craving. One care will continue to provide data and analytics that are trustworthy and actionable. As a provider myself, it's great to see more actionable reports coming out of one care, being made available so that we can see our progress and set new goals. To quickly demonstrate how this second core capability, data and analytics is being utilized by our members, we'd like to share a short video clip that demonstrates how our Brattleboro partners have used data and analytics to improve health and reduce costs in their community. We were looking at the data, one care data, not just for health outcomes, but also for cost of care. Every month, every quarter, our highest cost of care was all around cardiac events, heart attacks, transferring patients. We started to think about how we could intervene earlier with patients. That's where the idea was born for our cardiac prehab program. Patients who are selected go through the entire education series, the exercise series. They learn how to prepare meals, how to shop for the correct food. Think about it, preventing a heart attack. It means a longer length of life for that patient. It also drives down the cost of care. So as you can see, that was just a very brief snapshot, but I think one of many stories that are occurring across the state is we think about how providers are working collaboratively to use data to really innovate in their care delivery processes and to work towards providing optimal care for everyone that they serve. So finally now, I'm gonna move into the third core capability, which is payment reform. The goals of our payment reform programs are to stabilize provider revenue and healthcare costs and move away from the volume-based incentives inherent in a fee-for-service system. Again, as in several previous examples, we surveyed our network uniquely to this topic and we wanted to learn more about what is working and where we could improve. We learned that additional supports were needed and that these supports should focus on increasing participants' understanding of the payment reform programs that currently exist, how they are being refined, and how they work, so kind of the mechanics of them, and that people really needed a deeper understanding of that information as well as where they're going. There was also some helpful feedback about technical and formatting changes to improve PON existing reports to make them easier to understand or easier for others to explain them back to their teams. The chart on the right tracks the growth of non-reconciled fixed prospective payments over the past few years. That is the, those are the bars and kind of a teal color. And I think it's pretty impressive to see that really over the course of those four years, the value in those fixed payments has tripled. So I think we're on a good path there and again, more work to be done. Providers have shared with us that non-reconciled payments encourage flexibility in testing care delivery changes and providing stability to support the reform efforts. So now I'm gonna turn it back to Carrie for a bit more detail about some of the ways that we're supporting practices in payment reform. You've heard us speak earlier about One Care's Comprehensive Payment Reform Program, or CPR, which was developed to transition independent primary care practices to stable monthly fixed payments. These monthly payments are based on core primary care services. Non-core services, such as behavioral health provisions, procedures and labs, which are not provided at every single primary care site, can be reimbursed in a fee for service method as an add-on. The CPR program includes a supplemental per member per month amount to support care delivery evolution. And as you can see on this graph here, participation is growing. We hosted a series of focus groups this past summer to gather feedback and ideas from those participating in this. And these comments, ideas and feedback were considered in our 2022 program adjustments. And you have or will be reading written positive comments from some of our primary care members about this program and how it helped their clinics survive the impacts of the pandemic, and is also allowing them to recruit staff who are interested in working in a high value care environment. Next slide, please. We have and will continue to learn as we work together on the road to value-based care and improving the health of our population. We are committed to engaging and reaching out to our participants. And likewise, participants have shown engagement more and more and are willing to contribute to the evolution that's necessary. All of us affirm that we value a top-notch care coordination program. And that is it is essential to reach our goals in population health. Prevention efforts warrant more focus and energy. We are in discussions about how to push social, social determinants of health screening and response, food insecurity initiatives, movement and exercise programs, mental health screening and treatment, suicide prevention, return to work programs and others. Vermont's population deserves this. The COVID-19 pandemic has reinforced the importance of value-based care. It has jolted all of us to boost our support for providers to really engage in team-based care, to collaborate with our community partners, to participate in and expand coordination of care and payment reform programs, to fully utilize data and analytics and to encourage digital patient engagement via telehealth visits, e-consults, patient portals, et cetera. We are encouraged that providers have increased recognition of the value of progressive, capitated payment models. We fully admit that there's more work to do in the areas of education, engagement, equity and transparency. So we just wanna say thank you for allowing us at the time first to show you how we are advancing high value care, how we have honed in on our three core capabilities and what we are planning for 2022. And with that, I'm going to hand this over to Tom Boris, our Vice President of Finance. All right, thank you Dr. Wolfman. Hello everyone, Tom Boris, Vice President of Finance. Thanks for the opportunity to come and speak today about our budget. For a little bit of context, I view this one care budget as two components. The first being ACO program terms, things like attribution, total cost of care and risk. The second component speaks more to the one care entity budget and our operational plan and financial figures there. The presentation will follow that flow. I don't know. Whoever doesn't have their system muted, if you could so that we could clearly hear Tom that would be greatly appreciated. Thank you, Chairman Mullen. So this presentation will follow that same order. I'll start with some ACO program budgetary components and then shipped into the one care operating entity budget. As I go through the first part of this, there's an order of operations that we follow. I just want to point this out at the beginning to help enhance the transparency behind the way in which this budget is developed. So I'll try to call that out as we go that we're taking a stepwise approach. And with that, the real first step is the ACO provider community. So next slide please. See on the left hand side, our great state of Vermont. We continue to have a statewide network with participants really blanketing our entire state and some in the Lebanon area of New Hampshire. The number on this slide that continues to wow me every time I see it is the 288,000 people that we estimate will be attributed through our payer programs. This is my fifth budget for one care and I'm still amazed how far we've come in that period of time. We started in 2017, year zero of the all payer model with about 29,000 lives. That's 10 fold growth over a relatively short period. The other point I'd like to make with this slide that I think is really important is that we have a very diverse provider network. You can see all the different provider types listed. This is unique in my view relative to other ACOs that often start with primary care at the center and may have a handful of preferred provider relationships or established relationships with other provider types. We began out of the gate with a very widespread and diverse provider network. And I believe that gives us the opportunity to really effectively coordinate care across all the different providers treating our attributed population. Next slide please. So next, after we've established the provider network, there's a contracting session that occurs in the summer, proceeding any program year, then we shift our focus into the payer programs on offer. Next slide. The budget includes continuation of all the payer programs offered in 2021. Sometimes a goal in a budget is to grow and expand. Another time's a goal is to sustain what has been already established and built in this pandemic period, which makes value-based care more challenging than it ordinarily is. Sustaining what we already have, I think is a great success to this budget. COVID and the pandemic continues to create challenges for these programs, but also in my view and reinforces some of the points that Dr. Wolfman and Sarah May reinforces the need for value-based care. When we look at each of the programs, Medicare, Medicaid, Blue Cross and MVP, we're anticipating that the programs continue in a similar form and function. Each year we do sit down with the payer partners and discuss the program, what's working well, what changes might we want to build in. For 2022, we anticipate the changes to be relatively minor, but those negotiations are ongoing and we'll be sure to communicate with you if anything substantial were to come from those negotiations. Next slide, please. Next slide, please. Ginger, if you could, thank you, perfect. All right, so from the payer programs, again, going order of operations, actually if we go back one to the attribution slide, that'd be great, thank you. So from the payer programs, then comes the attribution estimates. So through our budget process, we do our best to estimate the attribution that will come to us between now and really a little bit into the actual performance year itself. We largely base our attribution estimates on the existing data that we have in-house and some rough assumptions about where we expect participation changes or other industry factors to come into play. We don't have the ability to run basically a mock attribution model that lives with the payers and they're working on running those attribution numbers for next year at present. Again, you'll see the big number, 288,000 lives anticipated in our 2022 programs, 257,000 of those lives we expect to qualify for scale. Where we're anticipating some change between 2021 and 2022 is in the Medicaid program. There's an update being processed to the way in which FQHC attribution is determined. So we expect that to deliver a modest uptick. We're also anticipating a modest uptick in the Blue Cross, Blue Shield of Vermont programs, both the QHP and the primary programs. This is a result of increased provider participation in those two programs. So we just estimate the number of lives we expect those new participants to bring into the program. All in all, another year with a tremendous amount of lives moving into a value-based healthcare arrangement. Next slide, please. Once we've established our attribution estimates, we begin our work to forecast the total cost of care targets. Move to the next slide, please. This slide shows in the bar charts on the top the anticipated 2022 total cost of care targets by program. $1.33 billion of healthcare costs moved into value-based contracts or continuing through in value-based contracts in 2022. Another big year. That's a significant number in my view to have transitioned into value-based care. As Vicki noted at the beginning of the presentation, Medicare looking to move all of those healthcare costs or attributing lives into some sort of a value-based arrangement. So there's certainly more opportunity for growth out there, but nevertheless, $1.33 billion is a large number. Impacts of the pandemic certainly challenge every aspect of our lives and forecasting total cost of care is no exception. A lot of moving parts and new variables at play resulting from the disruption the pandemic has caused and really affecting healthcare patterns makes it very difficult to project future year healthcare costs amidst the uncertainty around our healthcare system. These forecasts for the total cost of care figures, they flow and follow attribution increases, insurance rate changes or increases, COVID rebound in some cases and any other payer reimbursement modification. So we do our best through this process to really estimate what we think those targets will be. In terms of process, we are starting or in some cases already deep into the actuarial process whereby the payers establish total cost of care targets. We have the opportunity to review those, use our data to validate and ensure that we think that they're reasonable and then hopefully move forward with a program arrangement. Next slide, please. Want to spend a moment on program trend rates. This is a topic that often comes up due to the relative nature of the 3.5% in the all payer model relative to our programs. As I said, we use the best available data to develop these estimates and it very much is complicated by the fact that 2020 would typically be the base year for some programs and the way that these often work is that you have a base year apply trend or actuarial forecast to get to the actual performance year because 2020 is not a representative year. The challenge that we're facing right now is how to work around that unusual year. So we're in conversations with each of the payers. There are different perspectives. All have some validity to them. One perspective, for example, use 2019 as a base and do a multi-year hop, a three-year hop from that point forward. Another perspective is to use 2021's emerging trend as there are some new patterns coming out to establish the 2022 targets that has some validity as well. Third option is to do some sort of a blend where you blend multiple years together to try and establish a reasonable base. So challenging in a normal time, certainly more challenging through this pandemic. Next, I'll speak about the Medicare program a little bit as it relates specifically to the ScreenMount Care Board itself. There are some unique program factors. What we've decided to put into our budget model was for the end stage renal disease, ESRD and non-ESRD components, we relied upon the United States per capita cost trend forecast, that is the factor indicated in the Vermont All-Payer Model. This approach is intended to support providers and reform efforts, potential to affect the cost shift in a favorable way. Also, building off of the NORC report that indicated there's some savings being generated through our collective statewide effort here, seems like a really good opportunity to build upon the work that's already started here and maximizing the federal investment in our program seems like a good idea to me. The multi-payer advanced primary care practice component MAPCP, which funds the blueprint expenses were budgeted conservatively at 3.5%. The rationale for this decision was that the blueprint revenue stream, this funding stream that funds the blueprint did not face the same volatility that claims-based components faced throughout the pandemic. With that in mind, we elected a conservative 3.5% trend rate that aligns with the All-Payer Model growth rate. However, despite that assumption and the assumptions about the ESRD and non-ESRD trends, the rates will ultimately be established by the Green Mount Care Board in roughly the next month or so as you folks do your rate review for that particular program line. Next slide, please. Okay, so we budgeted the total cost of care targets. Really, now that ships us into the risk space and risk management, next slide, please. The primary reason to develop this total cost of care forecast is really to give us a sense of the risk and reward opportunity that we'll be taking on through these contracts and therefore passing through to providers. We are maintaining a moderated risk, aggregate risk level in 2022. After the pandemic, there are a couple of adjustments made to payer contracts to limit the risk exposure for providers that felt very reasonable to me. And we're continuing with this moderated risk level in 2022. I will point out though, it also limits the reward opportunity of the potential shared savings from these programs as well. We're starting to feel that pressure to make this model sustainable. We do need to have some returns through shared savings and limiting the opportunity in some ways is actually a ceiling for us. So as we're moving forward into the future years and hopefully get some stability back in our healthcare system, whether or not the pandemic is abated or not, really the stability is what we're looking for in the numbers, then we can begin to move towards greater risk and reward levels for providers to get back to what I think it was a more traditional level of risk. Next slide, please. I want to spend a moment on the risk and reward model and a little trip down memory lane back in 2020 in response to the COVID pandemic, some actuarial concerns around small numbers as well and resource constraints. We moved to a pooled risk sharing approach. However, in concert with this, we are starting and Sarah spoke with us earlier to include performance-based components to our population health management investments. And the point that I think is really important to make here is that we're trying to bring some synergy between these two components. Shared savings is one tool to use and the population health programs and investments is another tool and we're trying to make these two components really work together to thoughtfully spread accountability across our network without overloading community providers with untenable risk. The graphic at the bottom shows of those two components, shared savings and loss, a bi-directional era with the population health program accountability. Under the shared savings and losses component, it largely remains with the hospitals through this pandemic, gives them an opportunity to offset their participation fees, which I think is important. Pooled by HSA, we do have some HSA level performance factors and the accountability pool incorporates primary care of all types into this shared savings, shared loss model. Next on the right, if many of the one care investments now have specific performance-based components, as Sarah mentioned earlier, it's a modest transition to having a performance-based component and care coordination, for example, over time we'll evaluate that split. Those performance-based components mean that providers meeting or exceeding targets have the opportunity to earn more relative to their peers. That's the essence of value-based care, rewarding those who achieve excellent outcomes. One of the really important strategies behind this particular approach is that it enables the financial accountability to align with the size of the investments that one care is making into the providers. There's some balance here. With our community providers, we need to be thoughtful of their financial circumstance outside of one care programs. And if there is a large amount of potential downside risk placed upon those providers, we risk losing them from the network and that's an outcome that we prefer at this point. So we're really trying to right-size the accountability with other investments that are being made into the provider community. Next slide, please. So the moment on fixed payments. Fixed payments in a good way have been getting a lot of airtime lately and I thought it would be nice just to pause and share a few thoughts about the fixed payment programs. Underneath these total cost of care accountability programs, we're able to facilitate payment reforms for our providers. So that total cost of care contract is really the value-based care component. And then underneath that, there are some benefits that we can leverage. One is to change the way providers are paid. There's a lot of reasons to do this, but for me, really, I view this as a benefit to providers. Going back to my provider side experience, if I could choose a stable fixed payment over a variable payment, all else equal, I would have taken the stable payment every day. It's also a mean to stabilize healthcare costs under these total cost of care contracts. If you can lock in a decent portion of the healthcare costs, it helps to build some stability in these programs, which I think makes the transition into value-based care and accountability a little bit easier. All that being said, there are some limitations to what we can do with fixed payments. The first, we're limited by the contracted payer program, so we can only do a payment reform for programs that were under contract. Whether or not the payer program offers a fixed payment and those conversations continue, but not all came with a fixed payment option off the shelf. The size of the attributed population, we can do a payment reform for the attributed lives only at this point in time. Number four is important. Proportion of care in network versus out of network. This is not relative to where care is delivered, patient choice, or anything like that, but one care is not structured to pay out of network claims. For example, if an attributed life goes to Boston for care, Florida for care, we don't have the relationships of the contractual arrangements in place to pay claims for those particular providers, whether as a fixed payment or some sort of fee-for-service for them. So the reach of our payment reforms at this point in time is limited to those providers that are in our one care network and in the corresponding payer program. The last point that I think is important is provider readiness. It is easy to get the financial reforms out in front of the care delivery reforms. And I think it's very important for providers to be ready, not only to administratively handle the shift to a fixed payment, which hopefully in the long-stream is easier, but may not be on day one, and also be ready to make the practice evolutions necessary to succeed under a reformed payment model. So I'm offering here a couple of different ways to really measure the fixed payment evolution through these one care programs and the way I've structured this is to compare the fixed payments on offer relative to the in-network spend for the corresponding programs. Three views at the bottom on the bottom left, isolating just the public payer programs, which is where we began. We began it with Medicaid back in 2017, brought on Medicare in 2018. Of those in-network healthcare costs, 61% are now in a fixed payment model. I'll note Medicare is included in that. It does reconcile to be for service, but again, we view that as an on-ramp to the unrecognized models. I wanted to factor that in here. Next, the middle pie shows the percentage when you look at all programs that offer a fixed payment presently, 55%. And then when you look at all programs in totality, recognizing that some do not offer a fixed payment at this point in time, 41%. And I'll note those are 2021 data used for those illustrations. All right, this is the transition point. So the previous slides really spoke to ACO terms, concepts, and now we're shifting into really the one care entity budget and all the work that supports everything that Dr. Wolfman and Sarah spoke of and the ACO programs I just discussed. Next slide, please. $44.1 million budget. When I really think about the one care organization itself, that's the budget size that comes to my mind first. It is a balanced budget, no profit or loss planned through the budget model, no additional contributions to reserves in this particular year. Key strategies and in some cases, challenges is accommodate the end of delivery system reform and health information technology revenue, continue focus on care coordination. I'll speak to that a little bit more in a few slides. Sustained investments that have become reliable revenue streams for participating healthcare providers. This is something I think about often. We've been around now for a number of years. We've made population health management investments into providers in the $28 to $30 million each year. Many of those revenue streams have really been built into the financial fabric of our participants. And we need to be very thoughtful about the changes that we make. Last bullet, maintain capacity to support the provider network. I'll speak about that a little bit later in the presentation. In total, two big numbers to point out, 28.9 million of population health management program investments into the provider community and 15.3 million in one care shared ACO infrastructure. Next slide, please. Revenue highlights, main challenge in the budget is accommodating a $3.9 million revenue loss relating to the delivery system reform and health information technology funding. This was known that there was an end date for the, particularly the DSR funding stream. So through this budget really tried to accommodate and work with that known revenue loss. We're including consistent reform investments through payer contracts. Many of these are structured as a PNPM. So the revenue level will float with attribution, but in terms of the underlying model, the budget submitted includes a consistent structure. Deferred funds that accumulate largely to the pandemic and also some program ramp up have largely been consumed in 2021. This is a strategy to help us bridge through this really difficult pandemic period. Finite pool of funds that we use very strategically but does not available to us as we build our 2022 budget. And then in total to balance a $3.6 million increase in hospital participation fees. Next slide, please. We look at the numbers. About a million dollar increase in payer program support. Again, flows with attribution. You'll know the two negative numbers in the change column on the very right, the DSR funding, health information technology funding. Other revenues includes deferred revenues and the reduction there. And then the hospital participation fees increasing by $3.6 million. Next slide, please. Shifting over to expenses. Also two components to this, this the expense landscape here. One is population health management programs, funds that go out to the network to support our initiatives. The other is that ACO shared infrastructure. So I'm going to start with population health management expenses. In light of the revenue loss, trying to maintain as much of the population health investments as possible. Again, that financial, those dollars have really been built into the financial fabric and do not want to pull out the rug from our participants. Investments in care coordination were specifically identified as an area to sustain funding. As Dr. Wolf will mention, care coordination is often at the epicenter of an ACO model. And it is a program that requires hospital investment. Because of that last point in particular, we convened a group of our finance committee and population health strategy committee members to specifically discuss care coordination in context of the DSR revenue loss. That group made it clear that we need to continue to protect the care coordination investments and really rally around that program at the epicenter of our ACO care model. So despite some necessary changes, we are able to sustain 28.9 million of funding to participate in providers another year of really material investment into our provider community. Next slide. When we look at the population health management programs, kind of program by program, first area I'll focus on is care coordination. As I said, significant effort to maintain this program. Moving the financial model off of care navigator as Sarah discussed, despite that change, trying to sustain the actual investment amount in total, just change the way in which providers are reimbursed for their work. Each payment stream in this program now has a component for outcomes and performance, a really important evolution linking back to that risk management slide is that have the shared savings model, but we also are now building in accountability to our population health management investments. Continuation of the longitudinal care program for home health, encouraging outcomes from that program and reduced Dulce expense for one care, although happy to report that the program is maintained in full through additional support from the Vermont Department of Health. Top right, PCP engagement payments, primary care engagement payments. The revenue stream that historically supported these payments has been reallocated to support the care coordination program, having to make some tough decisions in this budget and with care coordination being a priority area we in some cases move revenue to support that effort. Value-based incentive fund, one of the more exciting evolutions that took place in 2021, I think relative to what Sarah presented earlier, but we're continuing to move and advocate for a real payer blended approach that enables one care to reward providers effectively and timely payments is one portion of this so that we're not making payments six to nine months after the years over and settlement occurs, but we're able to make payments throughout the year to keep quality and quality performance front and center for all of our providers. And that second point, practice specific quality score is being really important that no longer just distributing the value-based incentive fund based on aggregate performance but really evaluating each practice specifically and for those meeting the targets, making payments and for those with some work to do, helping to support those providers that they're included in the financial distribution in the next payment batch. Next slide. Prevention budget includes six months of the rise Vermont funding in the same form and then we're beginning work to determine the next iteration of clinical prevention and health equity. So transitioning our prevention strategy a little bit. Blueprint expenditures aggregate 3.5% inflation this goes back to that trend rate slide and the map CP adjustment that we discussed. Payment reform programs, this includes CPR program largely. We are anticipating additional practices so the expenses increased a little bit there. We're working on a pilot with FQHCs. It does not look like it will launch in 2022 gonna likely launch in 2023. We're gonna continue to work with the FQHCs throughout 2022 so that we're all ready in 2023 to go live with this particular program. Lastly specialist innovation fund, no new expenditures in this budget, but there are some expenses that represent a continuation of previously funded or obligated initiatives that just have continued on some delays through the pandemic is why we're still seeing it in 2022. Tom, before you get started on the population health investment areas, I think it would be good to take a bio break and if we could break till 11.05 and then come back and then we'll proceed till approximately 12.30 take a lunch break and then come back. So we'll put this meeting in recess till 11.05. Thank you, Tom. Oh, I see Tom now. Okay, Tom Boris, whenever you're ready to proceed go ahead. All right, thank you so much. The next two slides are included more for reference than for deep discussion. The first is a breakdown of the population health management investments by investment area. You can see the totals for primary care services, care coordination, quality, noting that the recipient types is a little bit different and that is the next slide. If that's one please. Shows the same total dollars but broken down by the organizational type, FQHC, designated agency, et cetera. Again, really in here for reference so you all can see the different breakdown of these population health management investments and then the corresponding program through which the investment is made. Okay, one more shift here. Now into the operations aspect and this is really the one care shared ACL infrastructure. From a landscape perspective, the resource demands from the provider network are higher than ever and that's a good thing. I'm really happy to see this but participants are asking for additional data, insights and direct support. There's an evolution here that I think is a good one. In the early years, it was all right, we'll join the ACL and see how it works and now there's a transition to help me understand my opportunities, what we can do differently. How do I stack up relative to peers? So really good and important transition here. We continue to operate a complex suite of value-based ACL programs. It takes a lot to run these programs, everything from data to the financial, actuarial, operations, many components necessary to run these programs as smoothly as we can. Participants need support to understand their roles and accountabilities. This was something noted in the NORC report as well and I agree with it that we have these complex ACL programs, we have a vast statewide network and there's inconsistent understanding of how everyone fits into the model. So we need to spend more time working directly with our provider participants to help enhance their understanding. Fourth bullet, we're a learning organization and we're maturing as an ACL and learning new things every day. It's easy for us to take those new learnings and just implement but it's better yet more work to really make sure that we're incorporating our sites and the providers and their insights into the work and the evolutions that we endeavor to make over time. So it's a good thing, it's good work to do but it is more and more work as we advance and mature as an ACL. In addition, similar to any other business, staff need time to meet demands outside of direct provider support that needs to be considered when we evaluate this budget and establish our needs. So in total, the bottom box, the operating budget aims to sustain the capacity to continue supporting participating providers while also being mindful of cost and if we were to increase the cost, that additional expense would be borne by the hospitals. Next slide, please. Next slide, thanks. All right, taking a look at numbers, 618,000 of expense reduction included in this budget. I'll note a little bit of a juggling act going on between the software informatics tools category and supplies, travel and other. We've reclassed or recategorized software professional services. So historically they're in that software informatics tools but the professional services are now contained within that travel supplies and other row. Most of the reduction that we're able to offer comes through restructuring our vital contract, collaboratively with vital. That's where most of the expense savings comes from. The staffing model that I'll speak to in a moment, very comparable year over year, basically flat in terms of salary expense and benefit expense. We're looking at the bottom left. We can see the expense by functional area within OneCare Vermont. I'll just point out the analytics bar, the gray section in the middle represents the software tools. Those software tools, though, support the entirety of the organization. For example, finance cannot, we cannot do our work without those underlying software tools that allow us to use the data so effectively. So while that is landing analytics, it's really an expense line that supports the entire organization. Next slide, please. Real quick look at staffing. Remains our single largest operational investment, largely a people organization software is behind as such a necessary component of the ACO work. When I was looking at this, I did point out in this slide, we continue to operate with over 16 fewer FTEs and planned in the 2020 pre-COVID budget. That's all to say, we had aspirations for new endeavors, initiatives, programs. Many of those remain unhauled as we go through this pandemic period, really mindful of the expense charge in the hospitals. All in all, when you look at the chart, pretty stable when you look at salary and benefit per FTE as well as the total budgeted or paid FTEs. Next slide, please. Take a look at operating costs over time and I have two perspectives here. The top one will be familiar, I believe to many of you. This top chart shows the efficiencies of a shared ACO infrastructure model. The one care operating expenses represent just 1.1% of the total cost of care of accountability through our programs. Every participant in our organization could build their own ACO and enter in their own independent ACO arrangements with payers, that is possible. I think it would take an inordinate amount of time and I think there would be duplicative resources. So really what I'm trying to show through this slide is that having a shared ACO infrastructure that all different providers across our state can tap into is a much more efficient model. Bottom left, we look at operating costs over time. The big reduction we made as I alluded to in the salaries slide was the change between the 2020 pre-COVID and 2020 post-COVID budget where we put on hold many of these new initiatives that we have planned. We continue to maintain operating expenses at this reduced level through the pandemic. I, again, when I go back to my thinking about a budget, sometimes it's a goal to reach two. Sometimes it's really more of a ceiling. I think in this particular case, it's the ladder. So maintaining this lower operating budget does limit the initiatives that we can take on. We'll continue to evaluate this over time as we potentially move to greater risk sharing arrangements.  Summary income statement along the left. I use some simple categories for the revenue lines, total cost of care targets, payer contract revenue, other revenues in hospital dues, total revenue, $1.365 billion. No, we don't touch all those dollars. Many of those funds are existing healthcare spends, dollars that we're accountable for, but they're in our total accountability budget. And then on the expense side, the actual health services, population health management investments and operating costs and a $0 bottom line. The pie chart to the right shows the relative proportions, 98.6%, 96.8 rather, rather of the budget. Health services spending 1.1% for operations, 2.1% for population health management investments. The way I think of this budget is that the 1.1% operation component and the 2.1 population health management component are the investments to help manage the 96.8% portion of this pie. That's what we'd like to see over time. Next slide, please. Included a little bit more detailed income statement and balance sheet. Apologize is small on this slide. I invite all of those listening to this meeting today to go on FigureBound Care World website. There are a number of Excel submissions that will have these data over multiple years in much more detail, but just wanted to include this slide for reference here. And with that, I am going to hand it back to Vicki. Great, thanks so much, Tom, for that presentation. And I just want to echo what Tom has been talking about for the past half hour or so, and that really this budget that we've designed in collaboration with our provider partners and our board is really designed to keep the momentum of healthcare reform going, even in the midst of all the challenges that they are faced with in terms of hardships for delivering care, hardships on their financials and sustaining their core business in order to keep their doors open. So with that in mind is I think about healthcare reform and making sure that we keep the momentum going. As I noted earlier in the conversation, this really takes a village approach to moving and transitioning to value-based care and accountable care relationships. And if you look at the box, it's on the right hand of my screen, it has the top three facilitators for maximum success and value-based care. And this was a survey that was done last year by HCP Land, which is essentially a consortium of healthcare leaders, payers and providers, whose goal is to really advance payment models that reward value over volume and getting to that preferred state. And what was pretty unanimous in that was that it does take a village, it takes providers to be interested and support this value-based care promotion, it takes health plans to be interested and ready, because remember, this is a change for them as well in their daily operations and how they work with provider communities. And it also takes government influence to be able to help support this change. And what I see in this budget and what I see through OneCare is you've got the first box checked on that through OneCare and its statewide network, you have broad accountability and engagement across 162 independent organizations. This is really unheard of in the healthcare industry and especially in the ACOs, I would say that we're very unique in that way. Over 5,000 providers serving Vermonters have come to the table to say, we believe that it's important to make this transition to value-based care adoption for both our practices and for the patients that we serve. And within that budget, it also talks about the population investments and continuing to invest in the delivery care so that the payment reform isn't the only component of it, because I think as we've talked through this, it takes both payment and delivery reform, so making sure that if we're developing innovative delivery reform, we have some payment or delivery reform to go along with it. And then thinking about how we consistently change our model, because as Tom also noted, we are a learning organization, so how do we adapt and adopt new ways of thinking and new ways of monitoring to make sure that we're continuously improving on our quality? And as I look to the next five to 10 years in CMMI's lofty goals of having all Medicare beneficiaries in an accountable care model, there's still a lot of work ahead of us that we need to do as a state and as a country, because this is a national platform that we're looking at. And a big component of it, and I think COVID has laid bare the importance of this, is moving away from that fee for service as the basis for setting these targets for the ACO, because the last few years have been anything but normal and the volatility in the numbers makes it exceedingly difficult to continue to look at fee for service as the basis. I think we want to make sure, as we noted, to maximize those risk and reward opportunities. We're at about $16 million right now, and we'd like that to be higher because with risk comes reward and with reward comes even more opportunity to make those investments in population health that we wouldn't be able to sustain right now if it wasn't for the hospitals really supporting this initiative. And then our work with both the Green Mountain Care Board and the Agency of Human Services is really working with the federal government to look at models that support rural healthcare providers and as a first step, getting them some clarity on critical access hospitals and how they meaningfully participate in this type of model. So I think that we should take a look at what we've done as a state and be proud of where we've come, even in the face of this pandemic that has hit us all at some level, including our healthcare providers and our patients. And we should continue to work together to move this model forward because the results are very promising and we just need to be ever vigilant in our approach moving forward. So with that, I thank you for your time. And I will turn it back over to Chair Mullen. Thank you very much, Vicki. And we're gonna start with our staff questions. I'm gonna turn it over to Sarah and Marissa. Hi, thank you so much, Chair Mullen. And thank you to OneCare for the very thorough presentation. This year, the ACO oversight team has prepared some staff questions at the request of the board. And those questions will be shared between myself, Sarah Kinsler and Patrick Rooney. So I'm gonna kick it off. First of all, we wanted to note that the staff has noticed as we've been going through the slides that there appear to be some discrepancy between budget numbers and FTE figures that are noted in the slides and in the submitted financial sheets. That's something we're gonna wanna dig into with the OneCare team, but it's likely not a productive time to do that now verbally. But we did wanna make a note of it that it's something we wanna connect back with OneCare about. Some of the figures don't appear to be aligned with the newly formatted financial sheets. There's a couple of places where we may note that and my questions are Patrick's questions. But so with that, I'll go on to my first question, which is in regards to the operating agreement, the updated operating agreements that we received that was submitted to the board from OneCare earlier this month, which reflects the change in governance in the member managers of OneCare, reflecting the change of the withdrawal of Dartmouth-Hitchcock health care as a member manager and how that affects both the operating agreement and the board of managers roster. So the overarching question is if you could take some time to describe the changes to the operating agreement at a high level and the impact of OneCare's board of managers roster, specifically if you could explain the rationale for designating an additional seat from the UVM Health Network. Just for everybody's understanding, previously there were three member manager seats designated for UVM Health Network, three member manager seats for Dartmouth in the updated operating agreement, the three Dartmouth seats. One is now designated for an academic medical center in New Hampshire, which would functionally be Dartmouth. The second is an academic medical center located in Vermont, which would mean there are now four seats for the University of Vermont Health Network, since it's our only academic medical center and the third seat is an at-large seat. So we'd like to hear a discussion of the rationale behind those changes. In addition, explain the reasoning for having the board chair limited to a UVM Health Network appointed manager. And I will leave it at that and let you respond and see if you have any follow-up. You're muted, Vicki. I think you're on mute, yes. Well, that's unfortunate, because I said amazing things in that time of being muted on the phone. I'm sorry, you missed that. So I'll take that for the team and then I'll look to my colleagues if there's anything else that we missed. So as part of the membership changes, there was some governance changes in our operating agreement, which you should have a fully executed copy of that. It did move the three UVM Medical Center member seat to UVM Health Network as the sole member of the organization. That left three Dartmouth member seats vacant. What we voted on as a board, and remember all of this goes through our board of managers and was fully approved by them as part of this process, is that two of the members of UVM Health Network of the Dartmouth member seats would be designated as academic medical center seats in New Hampshire and Vermont, serving Vermont ACO participants and participating in programs. Currently the two academic medical center seats are Dartmouth and we'll be voting on the UVM Medical Center academic seat coming up in the November board meeting. I think you also understand under CMS ruling, we are required to have a representational board that represents the constituents that have participation within the ACO. That's why it's very important that we have the academic medical centers as specific seats, just as we had federally qualified health centers as specific seats, independence as specific seats, so on and so forth within our organization. It's important to note that the UVM Health Network seats are not representational seats. They are member seats and they do not need to be filled by UVM Health Network employees. They can be appointed by UVM Health Network for anybody that will serve as an appointed member. So I just wanna make sure that that clarification is clear that they do not need to be UVM Health Network. Employees thus might not be participating in ACO programs. So that's why it's really important to make sure that you have those academic medical center seats. So I think that those were the major changes in the operating agreement. One care Vermont still remains an independent LLC 501C organization not owned or operated by UVM Health Network. They are our parent organization. So I think that needs some clarity because I've heard other members of the public say that we are owned and controlled and that is not a true statement. We still have a very independent board of 21 managers. The third manager seat we assigned to an MVP consumer representative. So now we have four consumer representatives on our board. Those were the only changes that were made to our operating agreement other than a very weedy change in that if the members of the board couldn't come to consensus, meaning the 21 members couldn't have at least 14 members agreeing on something is that in the past it went to dispute resolution between the two member organizations which were Dartmouth and UVM MC. Now it will be a special committee of the board that would contain the CEO of board member elected by the board who is not a member and a member organization. I wanna just emphasize that this is a tool that would only be pulled out in worst case scenario in that the organization would likely be contemplating folding. So this would be extreme circumstances that you would pull out this type of process or tool that we have in our toolbox. Those were the major changes to the operating agreement. I just wanna pause and also take a drink so I can get my voice back a little bit and see if there's any questions about that piece before I move on to the chair being a UVM health network appointed manager. Okay, thank you for that. Yeah, we noted that one change. So thank you for that explanation. I did just have a quick follow-up regarding your explanation of the appointed seats by UVM. Can you describe for us as a process and criteria for nominating and selecting those members? I believe it goes to the executive committee. So I'd be curious to hear a little bit about how that works or fill out my understanding. For the member seats, those can be elected at any time by the members. So that doesn't have to go through a board process. However, we have always made it a practice to bring these changes to the executive committee and notice to the full board of manager, but never at any point in time, even when Dartmouth and UVM Medical Center were members, was there a process to have those individuals approved by the full board? So that's not a change. Okay, thank you. Yeah, you can continue to the next part of the question about the chair, board chair. Yeah. So this was also a decision that was approved by our full board of managers. So just to provide clarity on that piece. And this provision was actually included at the request of the officers of the board, myself included. So I'm an officer of the board of manager who can be solely appointed or discharged by the board of managers, as is the chief compliance officer in that regard. So those are the two officers of the board. As currently sitting CEO, I felt that it was very important that the board chair be capable of linking the coordination of services between the member organization and the one care board of manager. And that coordination would be very critical to maximizing the efficiencies and cost savings that are intended to be achieved through these shared services between the two separate organizations. Okay, thank you. You're welcome. I'm gonna move on to my next question, which is in regards to one care staffing. So we had a couple of questions about the difference between the organizational chart that you submitted during last year's process and changes that we noted in the updated or the newly submitted organizational chart. If you could please discuss the following changes. We noted the elimination of an evaluator position, which I think was vacant last year and maybe discussed during these proceedings, but we noticed it's been eliminated. Also the elimination of the medical director role who I believe serves under the chief medical officer and the elimination of three of the five care coordination implementation specialist. Sarah or Tom, I'm gonna let you guys fight for who takes that one. Thank you. I can talk through those specific examples and then see if Tom has additional details to add. I think that a number of the specific positions that you just described, Marissa, were really contemplated in the transition from the 2020 to the 2021 budget. For example, a key component of the medical director's work previously had been in the sphere of education. And as we described in our testimony last year, we really were scaling back some of the clinical education, the grand rounds, some of the kind of older style learning collaboratives that we were wrapping up. And so that was really a decision made at that point in time. With respect to the evaluation position, that was a very hard choice in a budget constrained environment. I think if we had an opportunity, that's a position that we would continue to like to see. What we've done in its place is really a two-part strategy. One, we have a staff member on our analytics team who has a strong background in that area and we're working with him to expand some of his role in that direction. We're also looking at opportunities to work collaboratively, but more on a contractual basis perhaps with researchers from the Health Services Research Program at the University of Vermont to see where they might be able to contribute some unique skills and value that we can then capitalize on the expertise that we have in-house with our analysts to kind of build a complimentary program and at the same time have some efficiencies and cost savings in doing that. And then in terms of the Care Coordination Implementation Specialists, we as we were looking at kind of the 2020 to 2021 calendar year transition, we originally had a vision as we were expanding in the self-funded space that we would bring some Care Coordination Implementation Specialist positions online to do a lot of what we were thinking of as surveillance work. So it wouldn't be direct outreach to individuals in Care Coordination, but a lot more of kind of a monitoring function. And again, because of budgetary constraints, we decided not to move in that direction and through conversations with our network really have focused our Care Coordination Implementation Specialists and that very small but mighty team on working hard to meet the needs that people are reflecting today to make sure that we're most current. So I'll stop there and Tom see if there's anything you would like to add. I'll just add real quickly. Staffing changes are sometimes planful and that you're trying to build resources in a certain area and other times it's a response. Somebody leaves, we can't fill a position. So we really look at the staffing model very holistically every year through this budget process to make sure that we have the right resources in the right places within One Care and that's evolved over time. As I mentioned in the slide about the resource demands, they're different today than they were two years ago and really through the budget process we're trying to make sure that we use opportunities which might be a vacancy or staff transition at times to make sure that we can kind of shift our resources into a space that aligns with the strategic goals of the organization. Okay, thank you, that's helpful. I do have one more question about staffing. We do appreciate, we're happy to hear from Dr. Kerry Wolfman, your new Chief Medical Officer. We're actually wondering if she's available to come back on and just describe, give us an overview of the roles and responsibilities of the Chief Medical Officer. That would be helpful, thank you. Sure, thank you. I just started October 1st so I'm still learning about the role. I see the role as oversight for clinical and quality committee structures. So we have a population health strategy committee of the board and we currently have a clinical and quality advisory committee that is populated by our members. And so at this point in time, unless that structure changes, I will help oversee both of those committees. And stemming from those committees comes our work with population health in the areas that we described earlier today, things like quality metric evaluation and establishment and monitoring, quality improvement, focused groups and projects and the care coordination platform. I also think a big part of my role is establishing relationships with our members and with other key leaders at those member sites. So I plan to establish relationships with other Chief Medical Officers, other clinical leaders of various types and building those relationships, learning what the different members need and expect is a big part of the role as well. Any follow-up question regarding that answer? No, thank you very much. It's great to hear from you. Thank you. Okay, my next question relates to the value-based incentive fund changes. I don't know, first of all, I can't remember what slide number it was. I don't think I could see the slide number, but I wanted to just get a clarification. It appeared on the slide that it said the value-based incentive fund dollar amount is $2.2 million coming from hospitals. And that didn't seem to line up with my understanding that it's a million dollars in the financial sheets. So I was wondering if you could clarify that if I'm misinterpreting or if the $2.2 million number I'm remembering as last year, but maybe I misunderstood your slide. Sure, I'm happy to take that one. The $2.2 million is the 2021 amount that's obligated or directed through contract to us. The budget assumed that we'd be able to move to a different model. A little bit less funding in the pool really is designed to accommodate the revenue change that we have this particular year. It is a negotiated term. We'll see where it ultimately lands, but the difference there, versus our assumption for 2022. Okay, so the 2.2 is the 2021 number and then the assumption for 22 is the million. I know it gets a little confusing between the two years. So I wanted to clarify that. Okay, so that brings me to my question then, which is that the 2022 budget assumes the $1 million VBIF investment money from the sources and uses table that you provide us to have 6.4 in the financial sheet. It shows that that dollar amount is sourced approximately 460,000 from the Medicaid fixed payment allocation and 540,000 from hospital dues. Last year, we noted that the FY21 amount was sourced entirely from hospital dues. Can you explain the change in the funding source assumptions from 21 to 22? Sorry, I'm looking at the budget submissions. Really not a substantive change planned here. I mean, the value basis fund is a pool of funds that were obligated to generate through contract. We're trying to move away from that, frankly, to a different approach, but again, that's a negotiated term. The really at the end of the day, we need to come up with the dollars through some means. So it's either through hospital dues or that fixed payment slice off the top that we take and retain to fund programs. So in every year, one of the exercises we do through this budget is trying to do the sources and uses mapping to make sure that we have a clean accounting of all the funds coming into the organization. So I can look into that further for you, but really just at the end of the day, it comes from one care sources of funds that we need to be generated so that we can have that pool of a million dollars in this budget to be distributed out to providers who excel in the quality arena. Okay, thank you. And yes, of course, if there's things that we ask that you feel like you can't answer on the spot, we'd rather have you come back to us with the information than anything else. Okay, I think I will see if I have a follow-up. I guess I'll just ask this follow-up in case you wanna comment on it any further. You also submit to us a variance analysis that states regarding the BVIF lower funds budgeted to morph the program to a payer blended quality accountability model. So I guess we're just looking for a little more explanation. Sometimes it helps to hear it verbally about what this means and explaining sort of the year-over-year change in the BVIF. What we note in the financial sheets is that in, that there's been a reduction from a high of I think it's about 6.7 million in 2019. So trying to make sure we understand the variance as it shows up in the financial sheet how that relates to the evolution of the BVIF model. Sure, good question. So this strategy is actually something that we pushed for back in 2021's budget as well, where we can move off of the payer contract obligations and onto a value-based incentive fund model that is more flexible and allows us to deliver a better, more effective program to our participants. We made some progress in 2021's budget or negotiations I should say. I think we discussed this in the spring meeting but just to refresh everyone's memory, kind of got halfway there. Half was able to be moved to a settlement component. Half, we through contract must fund at 1% of the total cost of care. This relates to the Medicaid program. Because of that, the entire BVIF pool of funds is linked back to the Medicaid program. I don't prefer this approach and much rather that we could have this payer blended model, but we have limited funds. We cannot generate a mirroring 2.2 million for Medicare or another similar amount for a commercial insurer as well. So we're really pushing hard to build in the flexibility that we need to deliver a really good program to our participants. Great, okay, thank you. That helps. I asked or we might have some additional questions about this because as you know, the all payer model agreement requires a benchmark, shared savings, shared losses, or a combination or tied to quality of care or beneficiary and or beneficiary health. So we need to make sure we have a clear understanding of the relationship there. I just have one more question before I turn it over to my colleague regarding the payer program arrangements. Could you please describe one CARES non-scale target qualifying and or non-risk payer programs? What do you mean when you use those two terms in your budget submission? What are one CARES goals in engaging in such contracts and how does one CARES think they will support the network and the state more broadly and moving away from fee for service? Sure, I can take that one too. I wanna be careful not to speak on behalf of anyone else in this, but I'll express my understanding here. But through our Blue Cross program, there is this primary component which includes employer self-funded plans. Employer self-funded plans through their relationship with their TPA have an option of whether or not to be included in a value-based arrangement. That's the discretion of that employer plan. Some plans have opted out of that choice to move their program into a value-based arrangement which then comes through one CARE. So the non-risk lives reflect those, the lives from those employer