We can resume our hearing. We have two more agenda items this afternoon. We have cost share reduction policy update and we have a potential vote noticed. And then after that we'll have the monthly ahead model and global payment development update. And I'm not sure how long we'll go today, but we're scheduled to go till five. And so I'll turn it to Mike Barber on the cost share reduction policy update. I'm not sure board members have any questions or comments, but Mike, did you have anything to add at this point? I did want to add that we didn't receive any additional public comment, besides the comment that Mr. Fisher gave at the meeting last week. And I previously shared with you all the feedback we got from the carriers, which is kind of what prompted us to present two options for your consideration. So, and then Mr. Fisher had a question that he posed last week. And I think Kevin, if he's on the line is able to answer that. Are you on Kevin? I am, yes. There are some question marks and things where we'd be able to hopefully tighten things up a little more, but we believe that the initial proposed guidance would probably increase the APTC by about 15 to 25 million. And that the revised proposed guidance would increase APTC by about 35 to 45 million. Both of those relative to the status quo. So some error bars around it, but 20 for one option and 40 for the other. And that's all the new information I think we had to give you. We'd be happy to pull up the slides from last week and try to answer any questions you might have. Yeah, would you pull up that slide 11 to kind of orient the board members and then we can have any discussion or questions that there may have. Yes, just giving one second. Showing for you all. Yes, I'll open up to the board members for questions or comments or thoughts they may have on these various approaches. I'll jump in. So Mike, I know last week we went through sort of the differences between the two proposals. It seems like the crux of the matter is the enrollment assumption. And if I'm remembering, I know it was just last week, but it feels like it's like a month ago. So my apologies for not being crystal clear anymore. But I think the other states that have implemented are in the revised proposed guidance type area in terms of the enrollment assumptions or am I remembering that wrong? That's accurate. I think you're referring to New Mexico and Texas and while there are some nuanced differences between them, they are roughly in the camp of the revised. That's what I thought I had remembered. Any other thoughts from board members? And if not, are we prepared to vote? I forget if we have to vote today. Mike, can you remind me do we need to vote by today? That was the hope. There's no deadline to this. Obviously we want to get, I think both of these approaches would require us to get some information and then calculate a low that both carriers would have to use in their filings, which are due kind of beginning of May. So we were hoping to get moving on that, but there's no deadline. Yes. The only question that I would have is, I mean, the opportunity to bring in $40 million of additional federal subsidy to make health and transport from others is incredible. And the potential downside seems to be this, enrollment assumptions and assuming that people are acting quote, rationally in the economic sense of the term and purchasing plans that have financial interest for themselves, but are there, I mean, this thing, something else, is there another potential risk of doing this that you all have thought of? I mean, I'll kick it over to Jackie and Kevin if they have any comments, but I think they covered last week some concerns about just distorting the market and introducing some risk there in the event that one carrier picks up a substantial portion of the people in these silver plans. There's also the possibility that the enhanced premium tax credits go away after 2025, which I think, I'll look to Jackie and Kevin to correct me if I'm wrong, reduces the benefits a little bit and also kind of increases that group of folks who could potentially be harmed by this, depending on what plan they choose, because they don't get the premium tax credits. And then the other kind of potential downside that I see is, honestly, it's nothing compared to probably the upside that you mentioned, but it just makes us less comparable, I think, to other states, which I know you have brought up to me a couple of times, like in addition to strict community rating or peer community rating, this will just be another thing that we have to keep in mind when we're looking at how our rates compare to others when Kaiser Family Foundation puts out there their numbers every year that everybody looks at. That's, I don't know, Kevin or Jackie, do you have any additional thoughts? Not on my side, I think you covered, I was gonna say some of the things you were gonna say. Yeah, I would, I guess just mention, so as you talk about the destabilizing the market, one way of talking about it, right, is the concern is what if that 40 million all goes to one carrier or the other? And it's not just a concern about harm to the carriers given that this market is dependent on voluntary participation by the carriers, so worst case scenario there would be potentially real harm to the members if carriers, one or both, were to leave the market. Again, I'm not trying to suggest that's going to happen. You've read the carrier's feedback on this, but that's why we raise that as a concern. And then I think it's present for both versions of the guidance amendment that you're considering, but those actuarial kind of objections that we discussed last year in relation to this issue, this issue were still there. I don't think anything's really changed on that front.  I mean, we could change the guidance for 20 to reconsider it in that light, right? Is there a downside to that that I'm missing or something I'm not thinking about? Like it seems fixable in that circumstance or like a reconsiderable. Sure, I don't see any reason why you couldn't adjust it if that expansion goes away. Well, I'll just say for myself, I think we definitely need to revise the guidance so that it's clearer and we don't have the issue that we had last time. I can be comfortable with the revised proposed guidance, but I'm also, I could be convinced that taking a more modest step with the initial proposed guidance is the better way to go. So I feel pretty flexible on which of the two. So that may not help other people decide, but I'll just throw it out there that that's kind of where I am right now. So I'll chime in that I feel identical to member lunch. I'm comfortable with revised proposed guidance. I think the benefits in the upside are substantial. The risks can be mitigated if need be later and I am curious to hear if there's any public comment on this or if the carriers have anything additional to shed light on, but that's where I am. I guess I'll just say that I'm leading towards the revised proposed guidance for the reasons outlined in terms of the potential to draw down more federal dollars for remoders, but again, if there's public comment and there's something we haven't considered, I'm interested in hearing that. I'd always be interested in more information, but at the moment I'm in favor of the revised proposed. Would it make sense for me to make a motion and then we can move it to public comment, Owen? I think so. Okay, then I move that we approve the revised proposed guidance and delegate authority to Mike Barber to work with the actuaries to do the requisite calculations and compose the guidance document. I'll second the motion. And with that, I'll open up to public comment. We can go to the HCA first. Good afternoon, all. I think my comment won't surprise you one bit. I, as I said last week, I think this is a substantial gain. I think the pros far outweigh the gain, the potential cons, and I think it's been covered pretty well so your options to mitigate those possible cons should they arise. So I fully support and think it's a good thing for Vermonters for you to go to the revised guidance. Thank you, Mr. Fisher. Any other public comment via the raise of the hand function? I'm going to observe that this is a very eerie day and that we have had three presentations and not a single public comment. This is, maybe it's a first. Well, on that event, I will call for a vote. All those board members in favor of moving to the revised proposed guidance and delegating to Mike Barber, the drafting of that, please say aye. Aye. Aye. The vote is unanimous. Great, thank you. I'll share. Thank you, Mel. Our revised, I'll share the guidance when it's ready. Thank you very much. All right, and our last agenda item for today is the monthly ahead modeling global payment development update. And I'll turn to Michelle Degree who has been taking the laboring or for the care board and she is our health policy project director. And we also have our frequent guest, Pat Jones, the interim director of healthcare reform from the agency of human services. And I believe one of our care board consultants, Shulei Garovich from Mathematica Policy researches with us as well. So I'll turn to Ms. Degree and Ms. Jones. Thank you, Chair Foster. I'm going to go ahead and share my screen. Are you all able to see that? We are. Wonderful. So I'll be running slides, so Pat, as per usual, just let me know if you'd like me to advance, though I've seen them, so I could probably do it myself now. I will also start out by saying we didn't prepare a slide for this, but Pat and I wanted to highlight that there is our currently final global budget tag meeting scheduled for next Thursday, February 29th, which is a leap day. And at that meeting, we will be reviewing and discussing the differences between the states, sort of the tags work to date on the state-defined methodology. And what we recently learned last week from CMMI, CMS on their Medicare methodology as it relates to global payment for the AHEAD model, not something we had time to prepare for today, but is something that we'll be discussing with that group next week, and then we'll likely bring that back to the board at a future date, but wanted to flag that those materials are available on the AHEAD website for folks who might be interested in seeing sort of what the CMS methodology looks like. It's 186 pages, so Godspeed, but just wanted to share that with you all. So for today, again, as with last month, we're gonna do a quick review of executive session from me, and then I will turn it over to Pat to do sort of a revisit of the AHEAD model itself, quick background and overview of sort of where we are, an overview of those model timelines. And then today, we're gonna focus a little deeper on primary care AHEAD, which is something we haven't done in too much detail with the board yet. Pat will be leading, but I am here to assist as needed, and then we'll go into questions and comment, and of course, we've reserved time for executive session today, should any of the questions kind of go into the negotiation space. So with that executive session on the screen, you all are pretty familiar with this, but just a flag, there are grounds for holding executive session. We will need a motion to do so in the event that we decide to move to executive session and a vote for two thirds of you to say, yes, let's move. And then we'll sort of, I believe typically we pop back on to close the meeting chair foster, but I just wanna flag that this is a potential for today, not a guarantee, but in the event that we need to, you have seen the rules. And with that, I will turn it over to Ms. Jones. So thank you chair foster members of the board. My name is Pat Jones. I'm the interim director of healthcare reform for the agency of human services. I'm going to warn you that my internet appears to be a little bit spotty. So if you need me to repeat anything that I'm saying, please let me know. And it's the audio mainly. So what I wanted to do today was, as Michelle said, do some, we are in conversation. And then my understanding was that the board wanted more detail on the timelines for the ahead model, both in terms of preparing an application and if Vermont ends up moving forward with the model. So I'll provide a bit of information on that. And then really the bulk of the presentation will be devoted to a deeper dive primary care ahead as Michelle indicated. So next slide and the next one. So one of the things I've been doing lately in presentations is just, it's good to remind ourselves, I think of what we're trying to do here, what are our goals in healthcare reform? And so at the highest level, healthcare reform really is looking to use public policy to address challenges in the healthcare system. And this board certainly hears about the challenges daily in your work. But just to highlight some of them, we certainly ensuring affordability as a challenge and a key goal, improving access not only to care, but to insurance coverage as well, optimizing quality of healthcare. And that includes a person's experience of care as they access the healthcare system, improving the health of the entire population, improving equity and reducing disparity health of the ahead model, identifying social determinants of health or what CMS is calling health related social needs and determining how to address those, ensuring adequate workforce across all of our care settings, reducing complexity, and that includes burden for providers, areas where different payers may be misaligned. So what are some ways that we can reduce complexity and then creating a sustainable healthcare system? I'm sure there are others, but those are the challenges that we hear the most about and that have really risen to the fore. And so it's an ambitious undertaking, but that's the goal. That's what we're trying to do here. And we spend a lot of time talking about payment reform and that is one very key component of healthcare reform, but keeping in mind that it's really a means to an end. The goal is that the payment changes that we make would actually support care delivery transformation and that the end result would be better health outcomes for Vermonters and improved population health. So just wanted to take a minute to level set there. Next slide. So why are we considering a new federal model? As everyone here knows, we have a current model with the Center for Medicare Medicaid Services, CMS. And the really key element of that is that it's an arrangement between Vermont and the federal government that allows Medicare in particular to pay for healthcare differently and also Medicaid and our commercial insurers as well. And the current model really lays out some state level accountability around reducing growth and healthcare costs, improving the health of Vermonters and maintaining our improving quality and key measures. It has helped us shift from paying for each service in a volume-based fashion fee for service to more predictable and prospective payments that are linked to quality. And as everyone knows, it does rely on an accountable care organization in Vermont our ACO that implements this model is one care Vermont and the ACO and the providers that participate in the ACO have agreed that they'll be accountable for care, cost and quality on behalf of the folks that they serve. The original performance period for the model was 2018 through 2022, so five performance years. We are currently in the second year of a two-year extension period. So the model is set to end on December 31st of this year. CMS is quite interested in 2025. They see it as a potential bridge for future engagement with Vermont. And so really what our current model will be ending and what a new federal model would do is allow us to continue our healthcare reform efforts with Medicare involvement. Without a new model, Medicare would not continue to be involved. And I'll go into a little more detail in a couple slides on what some of the benefits of the head model in particular might be. So next slide. Just some background on how this all came about. We had been talking and other states as well with CMMI, the Center for Medicare and Medicaid Innovation, which is an arm of CMS. We have been talking about potential future models. They, on September 5th, they made a formal announcement about the ahead model, which stands for states advancing all payer health equity approaches and development. And then on November 16th, a couple months later, they released this notice of funding opportunity for the ahead model, which is really a call for applications. And so they invited any state and sub-state region so it doesn't have to be a whole state to apply for the model. The focus of the NOFO really is they wanna hear about what are states that apply. What are their capacity to implement a model like this? And then there is an offer of up to $12 million over the first five to six years of the model. How would they call that cooperative agreement funding? How would the states actually use that funding to support standing up the model? So that's really the focus of the application and the notice of funding opportunity. Link to the website here, lots of material. They keep adding to it on their website about the model. Key date, the applications for cohort one and cohort two states, there's up to three cohorts. The applications for those first states are due on March 18th. The third cohort has until August to submit applications. It's a competitive process. So CMMI is going to select only eight states or sub-state regions. And there does seem to be quite a bit of interest nationally. It's not yet certain how many will apply and how many will apply for the various cohorts, but there certainly is a lot of interest. I wanna really emphasize what the application is. The application is really the first step toward potential state participation. So it's the start of a more formal engagement with CMS. There's no guarantee that Vermont or any other state will be selected for participation in the model and there would need to be some time to negotiate an agreement in terms with CMMI and CMS. Then it would be time to think about moving forward, but really think of this as a first step. Next slide. So you've seen this before, this is a CMS slide, but it really does do a decent job of showing the ahead model at a glance. And so there's sort of three layers here. The first is what they call statewide accountability targets and there are three areas where they intend. Similar to our current model where we have areas of statewide accountability, they plan to hold states accountable for first of all, total cost of care growth. So that speaks to that cost containment and affordability area. And they will look at both Medicare. And when they say Medicare, they mean traditional fee for service Medicare, not Medicare Advantage. So how are we doing in Medicare and how are states doing in all payer total cost of care growth? Second area, and this will be one that I'll dive into in more depth today is primary care investment. They intend to have primary care. You see that as key for model success. And again, they'll be looking at that on a Medicare and all payer basis. And then there will be equity and population health measures in the state agreements and they'll expect states to set targets in that area as well. And for that, so the model is of longer duration than what we've seen in the past. It seems that CMMI has learned that it does for these types of large transformations, it takes time. So we're talking about models that are eight or nine years in duration, depending on which cohort a state is in. So for the accountability target show, we currently have some familiarity, like I said, with total cost of care growth, quality, population health type targets. The primary care investment is new, but it's an area that this board has certainly done some work in. And Michelle DeGray in particular has led that work. And then equity, that focus on equity is an important component of the model as well. So that's the statewide accountability targets. The three components that CMS highlights first, the cooperative agreement funding that I mentioned before, not a tremendous amount of money, but up to $12 million for spread out over five and a half years or so. And so that's, you know, to really help states think, you know, implement this model. And then hospital around the model and you've heard a lot about that in the past and we'll continue to hear about that. Ms. Jones, I'm going to let her up for a second. You're going a little bit in and out. Do you want to try it without the video just to see if it smooths it out a little bit? Sure, sure. My apologies. Oh, it's okay. Let me know if that works better without the video. It does. Yeah, let's try that. Sorry. Okay, okay. No, my apologies. I knew things appeared to be a little shaky, so. So then in terms of, you know, so those are the components, but how does CMS really anticipate that we will be able to achieve the goals of the model? And that's what these strategies really relate to. So first of all, integrating equity across the model. You'll see it in various components of the model. Second, they really see integration of mental health and substance use disorder treatment as being, you know, a key strategy results. They call it an all payer approach. They're really talking about, you know, at least multi payer. So a big focus on Medicaid participation and a big focus in sort of starting in the second year of the model bringing at least one commercial payer into the model and hopefully more. And then alignment across payers, but particularly they Medicaid. And you'll see that both in the global budget expectations for Medicaid. And you'll definitely see it in the primary care component of a head. And I'll talk about that in greater detail in a moment. And then finally, they have said that, you know, what they intend to do is accelerate existing state innovations. We think in the head model as we examine it that it definitely does help accelerate some of our existing innovations. There's some other areas, you know, particularly around primary care, capitation models where, you know, they're not quite where we might be in Vermont, but there's definitely a hope that there would be acceleration there. How's the audio? Is it better? Yeah, significantly better. Okay, good.  Thank you. Okay, next slide. So I had said a couple of slides ago that I would, you know, provide a little more information about, you know, what are the benefits of continuing to include Medicare and Vermont healthcare reform and particularly thinking about this model. And this slide's a bit of a work of progress. Keep adding to it a bit. But sort of that first row of benefits really speak to reimbursement levels. So, you know, one thing about participating in these types of models is that as opposed to Medicare fee-for-service reimbursement is for providers, it does give us some ability to influence that. The second thing is that, you know, Vermont for a while has been a low-cost state for Medicare. And so a model like this can continue to recognize that in the notice of funding opportunity, CMS definitely indicated that, you know, the expectations for high-cost states would be different than for lower-cost states. So there's some recognition there that there's, you know, there could be less room to improve. And then, you know, we have a number of reforms. We have a long history of engaging with Medicare. With CMS, for example, the support and services at home program is an example. And also, you know, our current all-payer model, all of those models have shown reductions in Medicare costs over what would be expected. And so, you know, continuing to participate with CMS can help make sure that those savings are recognized and potentially built into the model. So that's sort of the first row. The second row really speak one or an end of the third row really speaks to some of the dollars that could be coming into the state as a result of the ahead model and continued participation with Medicare. The first one, as I mentioned, is that up to $12 million in cooperative agreement funding. Second, Medicare currently continues to provide funding for a portion, it's portion of the blueprint payments and specifically for practices, primary care practices and for community health teams and for that SASH program. We get, as you know, because you've worked with it in your ACO budget efforts, we get between $9 to $10 million annually from Medicare, it goes through the ACO, but then it goes out to primary care practices and SASH and community health teams. Without, you can't see me shaking my head, no, but without Medicare involvement in not lose that funding. And it's really particularly significant for SASH because it's essentially the bulk of their budget. And then I'll talk about this a bit more in a moment too, but a way that Medicare is saying, they're saying we wanna see increased investment in primary care and they're actually putting their money where their mouth is. They're offering enhanced payments to primary care practices and if my math is right, it could approach $17 million annually if all of Vermont's primary care practices decided to participate in the AHEAD model. So just keep in mind, that's what they all did. And then in addition, there's transformation funding that CMS has said that they would offer hospitals that decide to participate during the initial couple of years of the model. So that would infuse some additional funding and there's a chance for upside funding based on performance on equity targets and measures and then some quality adjustments as well. And then finally, sort of a couple of what I put into the care delivery benefits area. One is when we get the major payers rowing in the same direction and participating in these models together, it does support greater alignment and priorities and payment mechanisms and models in quality measures and reporting and all of that sends a stronger signal to the healthcare system and hopefully helps alleviate some provider burden. And then part of participating in these models as well is that Medicare does sometimes waive certain Medicare regulations and give states the ability to propose some of those waivers so it can improve care delivery on the ground. And one example that we have in our current model is that the requirement that there be a three-day stay in a hospital before Medicare beneficiary can be admitted to a skilled nursing facility that three-day stay is waived in the current model. So that type of thing can make a big difference in how care is actually provided out in our communities. So that's just to continue Medicare at the table. How am I doing audio-wise? I'm seeing Effie. No, no, I was just messing around with you. Okay, okay, still okay. You're doing great, Pat. Okay, I can't hear you, but I'm assuming you can still hear me, so. All right. We can hear you great. You're totally fine. Okay, perfect. All right, great. Okay, so let's dive a bit because I know you had some interest in timelines. Let's dig into that a little bit. So next slide. This shows the key dates for those states that participate in cohort one. And we are intending to apply as a cohort one state. The difference is the same, but cohort two wouldn't start until January of 2027. And then cohort three also would start in January of 2027. They would just have a little longer to put their application in. So as I know before, March 18th right around the corner is the due date for applications from those cohort one and two states. CMS is saying that in the May to June timeframe, they will notify which states they have selected to move forward with discussions about the AHEAD model. Then there is what they call a pre-implementation period that basically extends from July 1st of 2024. And that cooperative agreement funding would presumably become available at about that time. And then that goes all the way through December 31st of 2025. And then the start of that in the case of cohort one states, it would be a nine year performance period. I'm going all the way through 2034. That would begin on January 1st of 2026. Next slide. This is a messy slide. And I'm gonna try and break it down for folks. It's a CMS slide and it's what they call operational milestones. And it talks about all the different things that need to happen once a state has been selected. So this would be during that pre-implementation period extending into implementation. We added the dates here to try and make it a little clearer as to what it would look like for a cohort one state. And I've color coded them here because I've tried to break down these timelines and these milestones into something a little more digestible. So I will do that on the next three slides, but I wanted you to see how CMS has laid this out in terms of what they see as the operational milestones. So let's go to the next slide and we'll see if we can make this a little more digestible. This is actually pre-July. So this isn't on the prior slide, but again, it's sort of a timeline of how the model was developed, the announcement at the application process taking us through CMMI selection of states. So again, we and other states were able to have some discussions about current and future models and what things might look like. And that occurred during 2022 and 2023. As I mentioned before, the model was announced in September of 23. The NOFO was released in November of 2023, cohort one and two states have till March 18th to apply. And then the selection again will occur in May or June of 2024. So that's sort of pre-implementation for the model. So the next slide. This, what I tried to do here was sort of pull the milestones together that relate to negotiations, execution of an agreement between states and CMS. And then the setting of statewide targets and particularly what CMS is looking for states to do in target setting is to focus on the all payer total cost of care and primary care investment targets. So the key deadlines there, if Vermont, and we've mentioned this in prior presentations, but Vermont is one of the states that if we're selected, when we look at hospital global budget methodology, we could either go with the CMS methodology, which Michelle referenced in her opening comments that was just released on Valentine's Day, the 182 page document, we can either go with what CMS is saying they're going to use for the Medicare hospital global budget methodology or states with regulatory powers like what the Green Mountain Care Board has can opt to do a Medicare hospital global budget methodology. And there can be some advantages there in terms of tailoring and so forth. And we've had a work group and others that have really focused on this. So if that's, if a cohort one state decides that they want to do a state specific methodology, Maryland's another state that certainly could because they've done deep work on hospital global budgets, that review by July 1st of this year because they generally need about 18 months to review, approve, get clearance and set up operations to pay differently. So that's a tight timeframe, but we have done quite a bit of work there. So July 1st of this year for that. The negotiations of the state agreement between a state and CMS would occur from July of this year through about May of 2025. So about 10 months, they want to have that agreement rounding and executed by July 1st of 2025. So that's why the May deadline to have things wrapped up. As far as those investment targets for primary care and total cost of care, those all payer targets, CMS is expecting states to either through executive order or statute or rule to establish at least a process for how those targets will be set. And that deadline is October 1st of 2025. And then finalizing the actual targets and getting them into the state agreement, they anticipate that that would require an amendment to the state agreement with CMS and needs to be done by October 1st of 2026. So a little bit after the start of the first performance year for those cohort one states. So that's, you know, that set of areas, negotiations, execution of the agreement and then setting the targets. Next slide. And then this really reflects key, what I'm calling key implementation milestones that were included on that messy slide. So the first relates to hospital recruitment. There is a requirement that in order for states to move forward with the AHEAD model that they would have to have recruited hospitals to participate in Medicare global budgets that represent at least 10% of the Medicare fee for service traditional Medicare net patient revenue. And that those hospitals would have to be under global budgets. And they're, you know, I have a key down there, but when they talk about Medicare fee for service MPR, they're talking about net patient revenue for hospital inpatient and outpatient services. So the deadline there is October 1st of 2025 to have a hospital in anticipation of one or more hospitals representing 10% of that revenue to an advance of that first performance here. The second thing, I had mentioned that they really want to see Medicaid involved in this model in a big way. And so they are requiring on the primary care side that there be a Medicaid primary care alternative payment model that's implemented prior to the start of that first performance here. And I will just note and we'll emphasize this later that the blueprint for health appears to squarely qualify as a Medicaid primary care alternative payment model and that is, you know, extensively implemented here in Vermont. So that should be an easy lift for a state like Vermont. Third, Medicaid is expected to also have hospital global budgets as well. And so the deadline there is by the end of the first performance year. So December 31st of 2026 that there be a Medicaid hospital global budget. Because of the current model, we certainly have some experience in Medicaid with prospective, you know, all inclusive population based payments. So there's some, you know, good and some work done to, you know, have a pathway into global budgets. So that is a requirement as well, but not till the end of the first performance year. By January 1st of 2027, at least one commercial payer needs to participate in the model. You know, the bulk of its business, it could be a self-insured plan. You know, there are a number of ways to meet that requirement, but you know, it's a lift to get commercial payer involvement. So January 1st of 2027 there. And then another hospital milestone is that while 10% of Medicare fee-for-service MPR would need to be under a global budget by October 1st of 2025, 2028 in advance of the fourth performance year, at least 30, their hospital participation would have to be such that at least 30% of Medicare fee-for-service MPR would be under global budgets by that fourth performance year. So those are, you know, what CMS highlights as their key implementation milestones. I'm hopeful that, you know, breaking the timelines into, you know, categories like this is somewhat informative to you all in terms of what would be ahead if we were to move forward with ahead. Next slide. So let's move on now to primary care ahead and I'll do my best to share details not only about what it looks like in the CMS model, but also how it compares to, you know, what we have now, not that what we have now will continue, but it's at least informative to look at what's in place now. Some of it will continue. And then I want to do, I do want to spend a few minutes just talking about some of the engagement that we've had around primary care with primary care providers. So next slide. This is a CMS slide. Actually, the next several are, you know, they're pretty good at showing what they're after here with primary care ahead. But, you know, this slide, you know, really shows at a high level what the program components and goals are.  It, you know, they're focused on advanced primary care. They want to, you know, they say align Medicare with state-led primary care efforts. And they really mean Medicaid there or multi-payer primary care efforts. You know, they do provide some guidance on what they would like to see or some examples of what they'd like to see in terms of care transformation. And, you know, with a focus on care coordination, connecting folks to community resources, improving quality, person-centered care and minimizing provider burden. So the goals of the program, I've, you know, mentioned several of these already, but certainly they want to see an increase in investment in primary care. They want to see payers aligned as much as possible. They want to support advanced primary care and I'll, you know, share a little more about that on the next slide. And in this model, they really are interested in seeing safety net providers participate both on the hospital side with critical access hospitals, but on the primary care side, they would like to see FQHCs, rural health clinics and, you know, smaller independent practices participate in the model. The sort of the components, like how they intend to support achievement of these goals are, first of all, through, you know, support for care transformation activities. They're intending to provide enhanced payments to primary care providers for Medicare beneficiaries. They also intend to provide learning collaboratives and supports other mechanisms for, you know, supporting promising practices and then data and technical assistance as well. So that's sort of how they see their role in supporting achievement of the program goals. Next slide. This just goes into a tad more detail on the goals themselves. I've already talked about primary care investment, but just to get a little more granular about that, what they're talking about is increasing primary care investments statewide as a percentage of total cost of care. So numerator, primary care investment, denominator, total cost of care, what's the percentage set at target for increasing that percentage? And as Michelle and others can attest, more than I can, that sounds like a pretty easy math calculation but how you define primary care investment and total cost of care can, it presents some interesting questions and challenges. So, but you all have done some groundwork on that, which is really helpful. Second, aligning payers. So the way they describe this is they say, you know, this model brings Medicare to the table for state led primary care transformation with a focus on Medicaid alignment. You know, it's a little different than how they're talking about hospital global budgets with hospital global budgets there. You know, as we said on February 14th, they released this very detailed spec. Here, they really appear to be looking to Medicaid to take the lead on what that primary care transformation would look like and they wanna be supportive of that. And so again, with the work that's occurred with the blueprint, the current model, Vermont is, you know, in pretty good shape in terms of having a model. And part of that is to really support advanced primary care and the way they describe that, I have a slide in a moment that goes into some examples that they've identified, but it really is looking at, you know, improving mental health and substance use disorder integration in primary care, care coordination and screening and addressing for health. Those are the areas that they've really focused on in terms of advanced primary care. And then again, that broadening of participation to practice types that may not have had the opportunity to participate in prior models. One of the reasons I include this slide too is that peach colored bar at the bottom. While the current include a capitated primary care model or track, they have said that they intend to introduce some form of capitation risk type model as an option for primary care in the future. And they've said maybe even as soon as 2027. And so that might be an opportunity where we, you know, for us to, you know, provide some insight given that under the current model, the ACO has worked with independent primary care practices on a capitated model. So that's something if we were to move forward with the model type. So just a couple of words from their website really on increasing primary care investment. I just wanted to highlight a couple of things here. The first, and these are direct quotes. The ahead model is designed to increase Medicare fee for service investment in primary care and align primary care transformation with existing innovations in state Medicaid programs. So again, you know, a very clear state investment increases and they wanna see that alignment with Medicaid. And then they do say that for that all payer primary care investment target that there is, they're gonna, Medicare is gonna calculate primary care investment how they calculate it. But they're saying that for states looking at the all payer targets and measurement, that there's flexibility for states to construct their own primary care definitions for spending measurement for all payer primary care investment targets. And so that's pretty important. Cause I, as you know, currently in Vermont, we have a number of, you know, non-claims type payments in the ACO model. There's a lot of prospective non-claims type pay for independent practices and also hospital-owned practices. There's the blueprint payments. You know, there's a number of non-claims payments that we have that wouldn't be included if you were just looking at a can't claim space measurement. So that's an important aspect of the model. Next slide. I did wanna share with folks and I'll do this later on in terms of the primary care model itself. But I wanna share at a high level what the application requirements are just so you know what we have to provide to CMMI in our application. And so as it relates to statewide accountability and the primary care components of that, I've highlighted and read where we have to, you know, provide information.  So that's one component. Another is how would we, if you remember in the timeline, we have to have a process for setting primary care investment targets. So they wanna know, how are we gonna do that? Are we gonna use state executive order, statute or regulation, you know, how could we enforce the process and the setting of targets? So that's another area that we have to speak to in the application. Third, they wanna know what is a state's ability to get information on primary care spending from commercial payers and Medicaid. You know, fortunately, claims database and so we have some information from commercial payers and we have the ability to gather Medicaid information as well. And then what are the policy levers that states can use to increase primary care spending by both commercial payers and by Medicaid? I'll note that one example of that is the blueprint statute that requires multi-payer participation in the blueprint. That's just one example. And then finally, that last row, what are known gaps in primary care spending reporting? I mean, one important one is the fact that B-cures don't self-insured data in it. So, you know, that's a gap. I know your team has figured out ways to estimate without some of that data. So that's just an example of where there might be a gap in reporting on spending. So those are the things I just wanted you to see like what we have to answer to in the application. Next slide. So let's, I hope you're all hanging in with me. I know this is a lot of information. I also hope you can still hear me okay.  So I wanna spend some time on really one of the key elements of primary care ahead, which is an enhanced primary care payment that Medicare is offering to practices that agree to participate in this model. So they are saying that they will provide participating practices with an average of $17 per Medicare fee for service member per month. So for those Medicare folks that are attributed to the participating practices and they've said they'll pay it quarterly. There's some adjustment to that based on social risk. So they're gonna pay a little more for social risk. If there's particularly vulnerable populations are being served in a practice, there's some quality adjustment. So there's some adjustments there, but in no way would the payment be below $15 per beneficiary per month and it would not exceed $21 per beneficiary per month. So a pretty significant payment that they're talking about making here. A small portion of that payment and they're talking about initially starting at 5% and then in the out years of the model scaling up to 10% would be at risk for quality performance. So I think it's 85 cents, initially, if it were a $17 payment and then up to $1.70 toward the end of the model. And I'll talk about what they are thinking in terms of quality measures in a little bit. So that's the payment. What's required to participate and receive that payment, the practices would have to be participating in the state's Patient-Centered Medical Home or Alternative Payment Model Program. Again, for us, that's the blueprint and about 130 out of a touched over 160 primary care practices are participating in the blueprint. So by far the bulk of our practices. The bulk of our practices. And then the practices would need to meet some care transformation requirements and their objective is to see that aligned across Medicaid and Medicare really for Medicaid to take the lead on that. And I'll dig into that too in a moment. And then how they suggest some potential uses for this enhanced primary care payment and they talk about investing in infrastructure, staffing, mechanisms for performing advanced primary care and they even give some examples of staffing types like care coordinators, mental health and substance use disorder treatment providers and then community health workers. So payment, what does it take to even participate? And then how can some of those, how can the funds be used? Next slide. This goes a little deeper on the eligibility criteria. So who can participate voluntarily in the model? Again, all types of practices, hospital employed, federally qualified health centers, rural health clinics, independent practices, as long as they're in the region that the application is relevant to, they can participate in the model. They also have to be participating in the Medicaid model which in our case would be the blueprint for health. And then a note about hospital employed practices if a hospital in the head model is part of the hospital global budget component then its owned practices are also eligible to participate in primary care ahead. If they're not, then they can't. The one exception for that is that if a hospital is affiliated with an FQHC or more likely owned those practices, those safety net practices can participate regardless of whether their affiliated hospital is participating. Next slide. So the next couple slides are our efforts to try and show sort of the current state of primary care payments and do some comparison between that and what is being offered under primary care ahead. So bear with me, you'll notice it says draft, this is a pretty dynamic environment but we've attempted to capture what practices currently get under Vermont programs. So that first light green couple of rows really speaks to practices that are participating in the ACO and there's a couple of avenues for them to receive payments. The first is for independent practices as you all know, the ACO has the comprehensive payment reform or CPR program. And there's just under 20 practices, is my understanding of the latest number that are participating in this program with one care. They receive a fixed prospective. So this is where the capitation comes in per member per month payment. First, that's intended to cover sort of the standard primary care practices, those evaluation and management codes that all practices use. And the way that that, my understanding is that the way that that amount is set is that one care has actually established some primary care spend targets and uses that as well as the funding coming in to establish that PMPM. For services that are outside of those standard services, you know, some of your non-core services, I don't know maybe labs could be an example, some practices provide that, some don't. Those are actually reimbursed a little bit higher than the fee for service rates. So, you know, it's reconciled at the end of the year to 105% of those rates. And then there's an incentive per member per month payment as well to encourage participation. And that's at $5, PMPM. So, you know, that's the CPR program, you know, a good chunk of the independent practices that work with one care participating in that and it provides some additional payment. All practices that participate, all primary care practices that participate with one care get what's called a population health payment. And that is the last I knew for 2023 and I think it might change in 2024, but it was 475 per member per month for each attributed life. The practices have an opportunity to earn a bonus of up to a dollar per member per month if they achieve performance targets for measures for selected measures. And I just want to note here that in terms of the Medicare members for all, you know, for these practices, they're getting payment for them, but Medicare is not contributing to that. So, you know, the ACO hospital dues, whatever, that's what is covering the Medicare portion of that. So while they're getting payment for Medicare members, it's not coming from CMS. So that's the ACO participating practices. The gray row talks about blueprint participating practices.  So practices that participate in the blueprint by virtue of their recognition as Patient-Centered Medical Homes receive a base per member per month payment. They vary by payer and Medicare is the lowest, but they do receive payments from each payer. The Medicare payment, again, runs through the ACO because we have a current agreement with CMS. If we don't continue to have an agreement, that would go away. And then the practices can earn up to 50 cents PMPM based on their performance for certain utilization and quality measures, but Medicare, they're not getting that through. Hey, Pat, let me interrupt. Yeah, has there ever 802-279-45 something or other? Just mute, please. Thank you. Thank you. So those utilization and quality payments, they don't get, the practices don't get that for Medicare members. Medicare doesn't contribute to that. They do get it for commercial and Medicaid. And then finally, the light blue row, the blueprint also has community health team funding that supports primary care. Sometimes it's passed through to primary care practices for them to hire their own community health team staff. And all three payers contribute to that for the base community health team staffing. Again, for practices that participate in the blueprint. And Medicare contributes again through that ACO payment. I do wanna note that Medicaid provides additional investments that can support primary care practices. Medicaid funds the hub and spoke program. So for primary care practice as a spoke, they'll get some funding to support staffing. Same with the pregnancy intention initiative. We have an enhanced pilot underway right now to support mental health and substance disorder treatment and health related social needs screening. And then the SASH program is almost wholly funded by Medicare dollars because it's a program for Medicare beneficiaries. But Medicaid does provide some funding for SASH infrastructure. And so again, in the dark blue, just to compare there, Medicare is talking about an average of $17 per member per month for those Medicare fee for service beneficiaries. Next slide is an effort to take some of, you know, to take that information and show how that $17 average PMPM that Medicare is offering stacks up against what's currently in place in Vermont. This is depending on what programs they participate in. So the column on the far left would represent a practice that is participating only in the blueprint, but not in the ACO. And so as I had mentioned before, that, you know, Medicare is paying $215 per member per month in blueprint payments. So that's what you see for the blueprint only practice. For a practice in the second column that's participating in the blueprint and in the ACO, but is not an independent practice that's participating in the CPR program, you know, they'd get a bit more. So they get the 215 from the blueprint. They get the 475-ish for the ACO's population health base payment. They have the opportunity to earn an additional dollar through the ACO if they meet, you know, performance targets. So, you know, sort of the total there if they got that would be just under $8 PM. I again wanna emphasize that the only thing that Medicare is paying dollars and 15. And then the third column shows independent primary care practices that are participating in the blueprint, in the ACO, and as part of their participation in the ACO are also participating in the comprehensive payment reform program. And so there you'll see everything that was in the prior column. And then, you know, there's the additional $5 PMPM that they receive for CPR. You know, what we can't really show here cause we don't know it is those non-core services that they might be getting additional payments for that's not reflected here. But it's an effort to show what it might look like for a PrAC, you know, I've heard anywhere from 17 to 19 practices, but it's somewhere in that neighborhood that are getting these additional payments. And so that's just under $13, you know, a couple of things I wanna, and then on the right, you see the $17 average PMPM for the AHEAD model. So a couple of things I just wanna make sure that we caveat, this doesn't include community health team payments. You know, again, practices either benefit from a centralized community health team staffing model or they might get some resources to, you know, to hire their own staff. You know, after 2025, the, you know, the payments that we're seeing that are part of the ACO would be likely to go away for Medicare. Medicare is not gonna, you know, they will still be involved in that model. And, you know, so there's just a couple of things that I wanna make sure folks are aware of there.  Okay, so trying to- Can I wrap up with a couple, can I wrap up with a couple of questions? Sure. And I'm hesitant to do this because whatever I do, like the next slide is what's gonna, like has all the answers to what I was asking, but I'm gonna try it anyway because I'm worried I'm gonna forget. Okay. What about the Medicare-only ACOs and the savings that they then share out with their members, like for, like, vitalizing those? Would those be included in this or is that separate? There are, you know, there are certain models that, that so when CMS puts out these models and I hope this is answering your question, sometimes there can be model overlap and sometimes there can't be model overlap. And so it's possible that a practice, the Medicare-only ACOs, is that ACO reach? Is that the model that they support? Yes. One is and one is not. Okay. Because there can be, there could be some overlap for primary care practices, but even more comfortable, like actually getting back to you on that because some of them, like, like I'll give an example, making care of primary is a model that CMS just released and primary care practices can't do that and ahead, but they might be able to do reach and ahead. And whether that means that how, how any savings that they pay out would, would mesh with the head, it's a little hard to say. One thing that Medicare doesn't wanna do is double pay. And so if they're paying out savings under one program and a provider's participating in another program, there might be some adjustments there, but I guess I feel more comfortable getting back to you on that if that's okay. Chair Foster, CMS released a crosswalk of all of their programs and I can make sure that that gets shared with the board and posted to our website. But like Pat, it also just came out and I do not have it memorized, so I can't, I can't confirm that right now, but it was released and I'll make sure that you all receive a copy and I'll ask Kristen to post it to our website. Okay, yeah, what I was trying to understand was like the total amount of money currently available in our programs, which are multiple, compared to the next model and how they stacked up. But then the second piece was my second question was, this is per member per month or per beneficiary, whatever it is, but the total amount to Vermont would depend on participation. So if the participation is much broader in the old programs versus the new program, the total absolute amount of dollars to this day could differ. Yes, that's correct. And you might recall that earlier I noted that there might be, you know, that it could approach $17 million in terms of these enhanced primary care payments, but that would be if all primary care practices participated. So it's, you know, that's a big assumption there. And I will note also that the $2.15, CMS has made it clear that that would not continue for the blueprint. So that you can assume that that's subsumed into the $17, which is why we show it the way that we do in this very complicated graph. They've also made it clear, though, that they would like to, if Vermont were to move forward, if we were to be selected and move forward with a head, they'd like to continue to provide the payments that they're currently providing to support community health team and SASH ongoing. How the mechanisms for that is going to be a little challenging, how the funding would flow, you know, what happens if not participate, for example, you know, so it's going to, there's some stuff that would need to be worked out there, but they have made it clear that they would be supportive of continuing those payments, presumably, because those are programs that when they've done their evaluations have shown savings and outcomes that they like to continue to support. And then one other clarification, which I think I know the answer to, the primary care ahead dollars that 17 or up to 17 million estimate for the state, that's all additive to Vermont, whereas my understanding is some of the ACO population health management and the CPR money, that's not additive for Medicare, it's coming out of hospital dues. Right, right, right. You know, the 215 blooper. Is, yeah. Just think of it in terms of the nine to 10, it's approaching $10 million now annually. That includes the 215 PMPM, it includes the CHT payments, it includes the SASH payments. The $17 is on top of Medicare fee for service rates. So for primary care, there's not downside risk here to participate in the ahead model. These are, this is Medicare's effort to say we are going to increase investment in primary care and here's how we're going to do it. It's a pretty healthy PMPM, honestly, based on what we're used to seeing. So, yeah. So it's the best, most raw way to consider this. Like I'm trying to figure out which gives us more money and I wanna make sure we're getting as much or more in the next effort. So we get nine to 10 million now for blueprint and SASH and this new model gives us up to 17 million, but it depends on the scope of who participates. Is that fair? Yeah, it's how many participate. And by the way, if we're not participates in the model in ahead, CMS has indicated that that nine to 10 million would continue. Or so, you know, On top of 17. You know, we'll see if we were to move forward, we would obviously wanna look closely at that in a state level agreement, but that has been the signal that we've received from CMMI. Ms. Garovitch has her hand raised. Thank you, Chairman Oven. So the issue here is on the participation, I just wanted to point out, hospital needs to be under global budget for the affiliated providers to participate, right? So it's not independent primary care providers joining and receiving the enhanced payment. So that's a little bit nuanced in terms of the targets for participation. It's linked with the hospitals. And then the other one, you did point out the hospital dues, I just to clarify, right? So that's the, I would consider that as a pass-through since CMS is paying that additional 10 million to the hospitals and hospitals are paying to the blueprint. Just to clarify that it is not coming from hospitals, budgets themselves. Is that true for the CPR program? So just to clarify, I think Sheila, you're right for the blueprint and SASH dollars, but for the 475 and the other dollars, those are actually the hospitals pay dues to the ACO, which is what forms those other payments. All right, thank you. Okay, thanks. Sorry to interrupt, Pat. That's okay. I actually had one other question on this slide. Should I ask it now or hold it? Or go for it. I mean, if the chair is okay with that. Definitely, please. So Pat, the other thing that I wanted to double check my memory on is, so the EPCP payments, how do those interact with the Medicare total cost of care? Are they included towards that target or are they excluded? I don't recall. So I'll take that one and answer it later. Yeah. Thank you. Yep. Okay. Shall I go on? Please, yeah. Okay. So this slide is again a CMS slide with a couple of additions from us, but what this does is it really outlines what their expectations are for care transformation as they provide these additional payments to primary care providers. And so they bucket them into really three intersecting areas. The first is health-related social needs. The second is what they call behavioral health integration. We call it mental health and substance use disorder treatment integration. And then they also have a bucket for care coordination. And what they've done here is they're providing some, these are really examples of the types of things that they would want to see in these areas from primary care supported by the additional payments. So under health-related social needs, they've included screening for health-related social needs. They give an example of efforts to identify and strengthen relationships with community resources and organizations that address those needs and social drivers of health. And then they also talk about incorporating onsite social workers, community health workers, other types of staff that could help with resource coordination. In the mental health and substance use disorder, treatment integration realm, some of the examples that they give are reporting on quality measures related to that care, developing warm handoffs to mental health and substance use disorder providers and managing medications for people who are experiencing complex mental health and SUD conditions. And then finally, under care coordination, the examples they give relate to coordination with specialty care. So they talk about aligning referral systems across Medicare, formalizing some of those specialty referrals and developing work streams that help establish relationships with specialty care providers. So those are some of the examples that they give, but those three areas are really what they see as key, the health related social needs, the mental health and SUD integration and then the care coordination. So next slide. Wait, Pat, can I ask a question before you move on? Sorry, just a quick clarifying question. Sure, sure. It says it includes at the top, it says includes care transformation requirements, but you were describing them as examples. So is this going to be mandated or is this going to be, hey, you could do this if you like to? I think what they're looking for, the best I can tell Dr. Holmes is that what I think they're looking for is that, again, they wanna take the lead from Medicaid. So I think they'll look for what, they wanna see the Medicaid Advanced Primary Care Program focus on some of these things, what is going to be required and then they would follow suit. They've talked again about coming to the table there. And I'm gonna rely heavily on the blueprint work because there's been some real focus in these areas and the blueprint for health. And so our intent would be to recommend those requirements as sort of the standard of care really. So I hope that helps. Next slide. So speaking of the blueprint, I did wanna take a little detour and just remind folks, some of the care transformation elements that are really already embedded in our blueprint for health. I mentioned earlier, most primary care practices are participating in. So the first is that for a practice to participate, it becomes recognized as a patient-centered medical home through the standards that the National Committee for Quality Assurance has put forth. And so that's sort of the entry point into the blueprint for health program. And then community health teams are doing a lot of that work related to health related social needs, mental health and substance use disorder treatment and care coordination. So they've been set up, each region has a community health team. They're multidisciplinary teams that the regions establish. Some of the examples of staffing include nurses, care coordinators, social workers, counselors, health educators, et cetera, community health workers. So what we see around the state is that in some cases that staffing may be located centrally and it becomes a shared resource. And that's especially helpful for patients and providers in those smaller practices. In some cases, the staffing is embedded in the practice, but the point is to really support access to those services and coordination of care. So this isn't like every state doesn't have this. And so it's a key element in addressing some of those transformation areas that CMS has expressed interest in. Next slide. We then have our extended services through the blueprint for health and I've referenced these earlier but the hub and spoke services for people experiencing opioid use disorder. So the hubs really focus on that intensive care and treatment and they're managed by the Vermont Department of Health. But then primary care providers and others, specialists as well, offer that office-based opioid treatment and those practices receive financial support from Medicaid but on behalf of the whole practice to support services for people that receive their care there. And then the pregnancy intention initiative. Similarly, this is a Medicaid-funded program. It can be for primary care or specialty practices. And the idea is to support people of childbearing age access to long-acting reversible contraception, enhanced screening for health and health-related social needs and then some brief follow-up, if appropriate, within the office and referral to health and community services. And then finally, the SASH program. SASH is again, almost totally funded by Medicare. So getting access to those Medicare funds in the current model and potentially in future models is essential to SASH. SASH provides wellness nurses and care coordinators, care managers to work with elderly and disabled Medicare beneficiaries. Many of them live in housing facilities, but the program is also available to people in the community as well. Next slide. And then finally, this is our current expansion pilot that's underway now. We received Medicaid appropriations from the legislature and the governor last session to implement a two-year pilot. It is focused on improving access to mental health and SUD services and on addressing social determinants of health through integration with primary care. And this really is squarely aligned with the priorities that CMS has identified in the AHEAD model, which is really encouraging. You know, we're trying to... I mean, you have heard about the concerns with increasing deaths from drug overdose and suicide and the acuity of conditions that we're seeing out in the community relate to mental health and substance use disorder. And as well, social determinants of health and housing is obviously top of mind for folks in the current environment. The idea is to make sure that people are screened for health-related social needs, mental health and substance use disorder that they receive brief intervention in the practice of appropriate and navigation to services if more intensive services are needed out in the community. And, you know, then primary care providers need support to do this work. And so the intent of the model is to use the community health team funding mechanism but to make sure that resources get out to practices to do this enhanced work. So the reason I added these three slides is because it really does, the blueprint really does quite well with what CMS has indicated they'd like to see in terms of care transfer me. Next slide. So a few words about quality. I had mentioned that those enhanced primary care payments will be, you know, adjusted for performance on quality measures. The way that CMS lays out the quality strategy in the ahead model is that they see there being three sets of quality measures. And all of them, by the way, having that health equity focus. So the first is statewide measures. And I mentioned that in terms of the statewide accountabilities. Second is primary care measures. And third is hospital measures or quality programs. And they've highlighted four domains. One is prevention and wellness. And there their goal would be to see equitable access to preventive services. The second is population health. And there they're focusing on improving chronic conditions and then achieving high quality, whole person equitable care across different population groups. Mental health and substance use disorder. They want to, comes there. Health care quality and utilization. There they've talked about reducing avoidable admissions and readmissions and then improving person experience of care. So those are the domains. If we go to the next slide, you'll see what they are suggesting for a primary care measure set. They're saying that they'll require five measures for those primary care practices that are participating in the ahead. And they've listed potential measures or their recommendations for measures. They have said that if an award recipient, and by that they mean a state or a sub-state region, if they wish to propose an alternative measure because, you know, to align with CMS would consider it as replacements as long as the alternative measure aligns to a domain below or to model goals broadly. So there's some latitude there, but these are the measures that they're recommending and frankly, they're, you know, familiar to us. We have some of these in our current model. They're, you know, some pretty standard measures. So under the prevention and wellness domain, they're saying that practices would need to choose at least one of these and the two that they recommend are colorectal cancer screening and breast cancer screening. Under chronic conditions, again, they're saying that practices need to choose at least one and there they are looking at controlling high blood pressure and hemoglobin A1C poor control for people with diabetes. For mental health and substance use disorder, they are requiring this measure unless an alternative is approved and that would be the screening for depression and follow-up plan, again, a measure that's quite familiar to us. And then under healthcare utilization, they're saying that both of these would be required, emergency department utilization and acute hospital utilization. So these are the measures that they're recommending are saying that they'll require for primary care practices that choose to participate. So five out of these seven measures. Next slide. Ms. Johns, do you mind if I interrupt? It might make sense to take a little break, I think just so people can stay focused if that's okay with you. Would this be, yeah, why don't we go ahead and take a little break? Why don't we come back at 3.05? So we'll just take like a 10 minute break. We can continue whenever you're ready. Okay. Yeah, let's go to the next slide, please. So in a similar fashion to how I shared the application requirements for the primary care investment work, this shows the application requirements in that notice CMMI put forth around their vision for primary care transformation and practice recruitment. So again, noting their focus on alignment with Medicaid efforts, the first row talks about I mean current Medicaid initiatives underway in primary care, and especially those that are related to mental health and substance use disorder integration, health-related social needs, care management and specialty care coordination. The second row talks about tools that might be leveraged to increase Medicaid investment in primary care, and they give some examples there. One thing I wanna note here is that, a lot of states have commercial or private Medicaid managed care organizations that are providing coverage for Medicaid beneficiaries in those states. And just to note that in Vermont, we do not have that type of a construct. And so Diva serves as the organization that supports Medicaid coverage. So that changes things a bit when you look at some of these requirements. Third, they talk about what are some tools for increasing access to primary care services. And again, they really focus on what's happening with Medicaid primary care alternative payment models, or FQHCs and rural health clinics participating in that, and how can primary care ahead align with those efforts. They asked for a detailed plan for recruiting primary care practices to participate in primary care ahead. And there they're saying, how will the state or sub-state region identify practices that are participating in programs and how will they conduct recruitment outreach to those providers? This is again where the fact that the blueprint for health is centered in the agency of human services, and we don't have those private Medicaid managed care organizations we know very clearly right off the bat what practices are participating and how to reach them. So, but they do wanna see that detailed recruitment plan. And then similarly, they wanna know what types of practices are currently participating in the Medicaid primary care alternative payment model and where are their gaps? And as I mentioned before, we have about 130 practices participating in the blueprint and the total, 60 or a little better. And most of the practices that are participating, they might be practices that are direct pay practices, so don't participate in Medicaid. They might be natural pathic practices, small independent practices, but there are, so we should look at that, but we definitely have most of the practices in our current program. Next slide. So I just wanted to spend a few minutes on how we've engaged with primary care providers. So this is our current advisory group structure. We have a healthcare reform work group that the agency of human services, as you know, and then there are some subgroups underneath that. And we obviously collaborate strongly with efforts, but we have a hospital global budget technical advisory group. There's a Medicare waiver technical advisory group and we have a primary care advisory group and I'll say a bit more about that in a moment. And we have a payer advisory group. Some of these are more active at different times than others, but that's the current structure. Two from before my time in my current role, but during the summer and fall of 22, some groups and that that really, you know, outlines some principles and really provides some foundation. One was a short-term provider stability work group that really looked at addressing some of those challenges in system capacity and the work is ongoing at AHS and elsewhere to really try and shore up some of those systems. There was a prior global budget group and a total cost of care subgroup as well, but the four that are currently active to varying degrees, as I said, are these.  Next slide. So, you know, here's some of the forums that we've used to try and, you know, share information and get input from primary care providers. The first is your primary care advisory group. So we've been to three meetings of that group, you know, talking about what's happening with healthcare reform and the AHEAD model in particular. And so most recently we were there on January 17th. And then as I said, AHS has the primary care work group that you saw on the prior slide. And that work group includes membership from primary care providers, leaders of associations. Michelle Degree is part of that group. And then a representative from One Care as well because of the CPR program. And that group has met seven times since October and we have at least two more meetings scheduled with that group. And just some of the material that I present today is material that they've seen and on primary care ahead and make sure we understand it to the best of our ability. We've met a few times with, there's a healthcare association coalition and that includes groups that represent primary care. So the American Academy of Pediatrics by State Primary Care Association, Health First and others. And so we've gone to several of those meetings to share what information we can and hear their questions and comments. And then there's ad hoc meeting requests, first leadership by state's board and so forth. So we're doing what we can to share what information we have with primary care organizations. Next slide. So I wanted to sort of end with this because I think it sort of circles us back to what are some of the challenges that we're trying to address. And so both at the January meeting of your primary care advisory group and then again with the AHS primary care work group, we asked a question, which is, what would great primary care look like for your patients? And so the next two slides attempt to summarize the really robust feedback that we receive from both groups. And you'll see that there, it won't be news to you for this type of feedback as well. But I think it just helps remind us what we're trying to do here on behalf of Vermonters in the area of primary care. So next slide please, Michelle. So the AHS work back, they said it would, what we'd like to do and what we think would be great primary care would be moving from reactionary crisis management to proactive wraparound wellness care. We'd like to be able to provide team-based care and to do that, we would want to see robust support staff so that includes nursing, mental health, social services so that we can address people's health related social needs as well as their healthcare needs. Reduced administrative burden is something that we hear quite a bit and this group highlighted that as well. Workforce definitely is a concern. So the ability to recruit more primary care providers and ensure that they're properly supported in order to meet people's needs. Discussion about let's transition, it would be nice to be able to look at a whole, a total patient panel and make sure that the way that we're using our resources ensures that they have access to the care that they need. They talked about increasing engagement with the community and also making sure that there's outreach to populations and people who may not be seeking primary care. And then eliminating barriers, administrative barriers, regulatory barriers that prevent practices and providers from offering the best possible care to their patients. So that's a summary of what we heard from the HHS primary care work group. And then if we go to the next slide, you'll see a lot of commonality and there is a little bit of overlap between the two groups, but not much. And so you'll see similar themes from the primary care advisory group. One provider from the PCAG said, time with patients is really the currency of primary care was the way he put it. And so ensuring that there's adequate time to listen to patients and to talk about options and sort of in concert with that, trying to achieve some reductions in paperwork. In other words, it shouldn't take more time to document a visit in an electronic health record than the time of the actual visit. Availability, this speaks to access patients being able to see providers when they want to, primary care being close to home, and everyone in the state having a primary care provider and seeing them each year. So having been seen in the past year for the care is affordable. And again, talking about sort of panel sizes, one provider talked about having a panel of about 1,500 patients and that that was really too much, especially when thinking about the complexity of many folks. And so she suggested that 1,200 per provider might be a more reasonable panel size. Again, this group talked about team-based care and preventive care and a desire to be able to support people in addressing health-related social needs like housing and food insecurity. Physicians and nurses being supported to work at the top of their licenses and flexibility and creativity in how care can be delivered. So in addition to office-based visits, what about home visits, or good team-based care? Providers talked about a capitated payment and value-based payment and emphasize the value of the CPR program or something similar to that. Making sure there are adequate resources outside of the office, so the ability to make those connections for patients to mental health care, home health services, rehabilitation services and others. Similar to the AHS group, how can we encourage more people to go into primary care? Can we prioritize primary care and training? And then noting that some people may continue to see specialists when it's appropriate for them to go back to primary care once they've achieved some stability. So just making sure that care is redirected from specialists to primary care when appropriate. So that's all I had in terms of slides. Again, wanted to end on that because I think it circles back to what do we hope for? What are our hopes and dreams in this work that we do and how can we address some of those challenges in healthcare? Thank you. Thank you for your patience and time. Thank you for spending your time with us. I'll open up to the board for any questions or comments they have for Ms. Jones. I'll just go ahead and jump in. Elena looked up the answer to my question. So I thought I'd just mentioned what that is so that Pat doesn't have to follow up with that in case others are interested. But the 17 p.m. p.m. is not included in the Medicare total cost of care performance totals in the first three years of the models which I thought was interesting because it shows sort of an interest on Medicare's part in investing in primary care early in the model. So I just wanted to say that out loud so other folks would have the benefit of that information and thank you to Elena for multitasking and sending that to me. Thank you. I would have guessed that they would wanna show that support so it's good to hear. Thank you. Yeah, I'll jump in next I guess. Thanks Pat for coming in again today. I've really appreciated the monthly updates and I've been trying to follow the CMS and CMMI websites to learn more about the AHEAD model. And I've got a couple of concerns that I wanted to talk through. I don't know that anybody will be able to answer them directly, but I wanted to share them. And I guess first in lines with the 17 million that we've been talking about, my understanding from the websites and other information is that that would include the nine million for a blueprint, it wouldn't be 17 million in addition. But I'm not an expert, I haven't spent as much time as others, but it's a big chunk. So I wanna stick a pin in that to look at further. In addition, a lot of the dollars that were described today, my reading from the websites, they are dependent on provider participation and successfully meeting cost reduction targets. But participation has always been limited among Vermont providers. We haven't met any scale targets for the first all-payer model and we were reprimanded for falling behind before COVID. We also have a low cost state for Medicare that's been said over and over. So it'd be, I think it'd be difficult to reduce our cost much further. So I worry that the model's not tightly aligned with what Vermonters need right now. And for that reason, because there's not tight alignment, I think CMS could also see that and that because they see there's not a tight alignment with what we need and what we can provide them, that we may not be selected. And we saw a lot of information today and we have over years about the great benefits that Blueprint and Sash bring to Vermonters. But I haven't heard a lot about developing contingencies for how we'll fund those services if we're not selected. And that's a big worry of mine. I worry about that because the model, the head model is meant to help control Medicare's expenses by reducing the amount of money that it pays out to providers, particularly hospitals, because that's where the money is, those are the high cost things. CMS thinks that we could reduce cost to Medicare if we reduced overused and unnecessary hospitalizations. And it introduces this idea of the idea of equity because in places that have decreased utilization across the country, the utilization has dropped most among brown and black people. And so the model's meant to incentivize a reduction of utilization, but to make sure brown and black people continue to gain access to the care that they need. So the equity component's new, but the rest of the model isn't. It's based on the ACO model that we've been grappling with for about a decade. So I think that that's important because we don't have a lot of brown and black people in our state, we're pretty homogeneous. And so the lessons learned from our state in regards to equity, I think it'd be hard to generalize that to a more heterogeneous state. I think the reason that CMS wants to invest so much in primary care isn't to reduce primary care administrative burden or increase the amount of time they have with patients or to reduce panel size. It's because an investment in primary care can lead to better care of patients with ambulatory care sensitive conditions. And that in turn would reduce hospitalizations. The, these models are meant to reduce the utilization of unnecessary or overused services, but in Vermont, we don't have an overutilization problem. In fact, just a couple of weeks ago, Diva was presenting to us and described a report by Mathematica from December of 2023. And they found little overuse or unnecessary hospital services for patients with Medicare in the state. And that's consistent with Dartmouth Atlas data that goes back decades. And meanwhile, the Kaiser Family Foundation and others, including a report by Wakely consultants just a couple of weeks ago, tell us that the big problem about healthcare costs in Vermont are prices. The Wakely consultants calculated that 88% of the increases in insurance premiums were due to high hospital prices, while just 12% was utilization. So we don't have an overutilization problem, we have an access problem. The AHEAD model is a complex multi-tool to reduce overutilization, but we need something like a screwdriver or a simpler tool that addresses prices. So I don't think there's a good alignment between what the tool, what the model's supposed to do and what Vermonters need. And I think, and as I said, I worry that CMS is gonna see that. They're gonna see our cost and pricing and racial data. And we may not be selected. And we can't achieve as much savings for them. And any findings about equity from our state won't really generalize to a less homogeneous state or a more heterogeneous state. And so that creates this angst for me that if we are selected, the model may not address our needs, but if we are not selected, we'll lose blueprint and sash funding. And I haven't heard much about contingency plans for if we lose that. So I wanted to share those concerns. And I wanted to thank you for coming in again and talking us through this. It's an overwhelming amount of information to try to follow. So I appreciate your time and the chance to share these comments. Thank you. Chair Foster, would you like me to try to address some of this or? You're welcome to if you'd like, sure. Sure, I'll give it a shot. I took notes. Thank you, Member Walsh. So I guess I'll try and go into order with some of the concerns that you've raised. The first in terms of the nine to $10 million our understanding from CMS is that that would be in addition to the enhanced primary care payments. So we could continue to, we were select into negotiations with CMS. We would certainly want to be very clear and verify that. In terms of the funding, and again, that 17 million was an estimate. And in terms of that being dependent on provider participation, that's absolutely true. What we've seen is good uptake in the blueprint for health. We've seen good, the majority practice participation there and in the ACO programs. And so while it is definitely dependent on that, the fact that it's a upside only program, there's not downside to risk for providers, whether that would encourage them to participate or not hard to say. I do want to note that if hospitals don't participate, then their own practices would not be able to participate unless there were all health clinics. So that's definitely a risk. And I want to make sure that I don't gloss over that. The low cost state reducing costs, I think that again is going to be something that we're gonna, if we were selected, we'd really want to focus on in discussions and negotiations with CMS. CMS has very clearly stated publicly that they realize that budget neutrality might be a more achievable goal, particularly for low cost states. So we have heard and that they're really focused on equity quality as well. And so we want to keep tabs on that because that's going to be really important in terms of whether this is a model that works for Vermont or not. And as you said, it's not a done deal that we're selected. So contingencies in terms of Blueprint and SASH, Blueprint is a multi payer program. So we would continue to have presumably Medicaid involvement, commercial involvement in the Blueprint. SASH is a greater risk because as we talked about earlier, I mean, it's a risk for Blueprint too because the Medicare component is important even if they're not paying for every element of the Blueprint. They're paying for patient centered medical homes. They're paying for community health teams, at least that core community health team component. So that's a risk, big risk for SASH. And I think that's something we'd have to talk about collectively with state leaders on that one because it's a concern. And again, you mentioned controlling costs and reducing costs. That's, it's gonna have to work for Vermont where it's not, let's keep reducing costs if there aren't places to reduce costs. Equity, there's some opportunities in Vermont. There's black and brown people, as you mentioned. There's, there's morality, there's socioeconomic status. You know, the health department is currently engaged in some community work around what the next state health assessment shows and what the next state health improvement plan should look like. And there's some clear focus on equity there. So there are opportunities. And part of it with Vermont is we do have small numbers. I mean, we're a small number state period. And so it might limit either what measures do we look at? You're gonna need to look at measures that a large segment of the population is eligible for. It might mean looking at multiple years of data, but you know, we, it's an area that we can and should focus on. So recognizing the challenges, but also recognizing the opportunities there. And then, you know, the discussion about why primary care investment. Yes, I think it does, you know, have some opportunity for improving results on those ambulatory care sensitive conditions. You know, there's research that shows that investment in primary care leads to better outcomes as well as better financial picture. So, you know, don't disagree with you there on the mode of for increasing investment in primary care, but it's an area that's being talked about nationally and that, you know, other states are looking at as well. So, I mean, I know I kind of superficially touched on a lot of the points, but hopefully we can keep the discussion going. Hopefully that's helpful. But, you know, I'll say again, the application is the first step. You know, we'd have to get selected and it would have to be a model that made sense in Vermont. If we were not selected or we did not wish to proceed, will healthcare reform come to a screeching halt? No. We have Medicaid efforts in healthcare reform. We have commercial payer efforts in healthcare reform. Does it help a lot to have Medicare at the table under the right circumstances? Yes, it does. Thank you. Well, thank you, Pat. Thank you for the willingness to dialogue. I do want to say just one more thing with equity. I did not mean to suggest that we don't have equity challenges in our state. I strongly believe that we do. But my point was that in, there were a homogeneous state and it's sometimes easier to make decisions about what to do in a homogeneous setting. A lot of people point to Scandinavia as an example of this, that they're able to come to a consensus about an approach more easily than countries that are more heterogeneous where there's more tension between the majority and minority groups. So I think that that's where we don't quite, I don't know how valuable CMS would see us because we're so homogeneous. But we do have a strong history of a solid working relationship with Medicare. And I think that that's valuable. And I appreciate all the work that you're doing to try to shepherd this through. But I just, I wanted to raise my concerns because Vermonters are paying me to think about these things and share my concerns. So I appreciate you listening and I appreciate the polite dialogue back and forth. Thank you. And I'd really, and likewise, I'd really like to also give a nod to the Health Equity Advisory Commission and that's been established and we've been able to meet with the co-chairs of that group. And, you know, they're interested and excited and working together. And so I just wanna give a nod to them and thank them for being willing to teach us and talk with us. And also the Vermont Department of Health for the work that they're doing that arena as well. So thank you. I'll hop on next. So Pat, thank you. You know, I can imagine all of the teams that are doing hard work here and the hundreds of hours that have been put in to try and think about this model and to try and, you know, make this application. And, you know, every time you come, I realize there's lots to like about the model. I think the focus on equity, I think the focus on primary care and primary prevention and, you know, enhanced payments are all hugely, potentially valuable to Vermont. And so there's plenty to like about the model and I think it's definitely worth exploring and I'm glad that we're applying for it. And I recognize that just applying for it is the start of a long process. So what I'm about to say is about what I'm hoping we'll see in that, you know, post-application time period before we have to sign a final agreement, the types of analyses that I think would at least help me and I'm speaking just as one board member who may have to vote on whether we go ahead with ahead. I'm just thinking in advance and thinking about what I would, it would be helpful for me to see, to feel confident that I'm making the right decision for Vermonters. So one of them is an evaluation of ahead against the next best alternative. So I know I've mentioned this before, but what happens to use Tom's language a bit? Like what is the contingency plan here or what is the next best alternative? What other healthcare reform, you know, efforts have been considered, evaluated and decided we're not as good as ahead. And, you know, the things that we can throw out there could be reference-based pricing. It could be rate setting with targeted increased reimbursements for primary care, for mental health, for substance abuse. I mean, there's things that we could alternately do and consider. And I just think if we could understand what that next best alternative is and then compare what we expect to come from ahead versus that next best alternative, whatever it is, what are the federal dollars coming in under each model? What is the cost containment expectations under each model? The access implications, the equity implications, the quality implications, the workforce recruitment and retention implications, the administrative cost implications under each model. I think that would help me know that we're making the best effort here. If you think about your slide seven, which I think is a really good slide, it lays out all of the challenges. I don't know if Michelle, you can just pull that up for a second if that's possible. It's the one where it's why healthcare reform. I think it's a really good slide. It lays out the challenges. What would really be helpful to me is to be able to look at all of those bullets and say, under ahead, we're gonna do better on all of those bullets than under the next best alternative, whatever that might be in terms of healthcare reform. So knowing that this is our best approach. And I think for me also, I think we have to have a real conversation. There's no model that's perfect. Every model has intended implications and unintended consequences. And so for me to be aware upfront of the downside risks and then to develop strategies to mitigate against those risks is really important to have those conversations soon before we embark on a new model so that we know that we have the mitigation strategies in place. And so I think access is coming up as a, for example, one of the potential downside risks is there less incentive to solve the already prominent access challenges that we have in the state? So how do we address that? The other one, as this bullet point suggests, is insurance coverage and commercial. And how do we think about, the model will probably help us contain costs for Medicaid or be budget neutral for Medicare potentially. What are we doing about the commercial side of the population? So how will we ensure through this model affordability for commercial ratepayers, for businesses? How will we ensure insurance coverage is going to be a possibility for people who are in the private markets? So I want to think about that so that we can, again, think about strategies to address those. I also want to think about and would be helpful for us to understand the systems preparedness. Is the system prepared? Have we done an assessment of whether we have the infrastructure in place for success? Do we have enough long-term care beds and mental health beds to be able to move people out of hospitals and into those more appropriate care settings? Do we have the workforce in place to be able to ensure that we can actually meet the primary care targets that we're going to be setting and to be able to reduce the avoidable care that perhaps exists in the state? Do we have the data analytics tools and the care management tools and the health information necessary to be able to make this work? So I just want to make sure that we're assessing the systems preparedness. And if we were to assign the agreement as we're thinking about the agreement, the regulatory apparatus is to develop, for example, global budgets, to monitor hospital performance, to mitigate against some of the downside risk is not inconsequential. So an analysis I think we would need to do and make is how much fee for service revenue must be, for example, in a global budget to make that all worthwhile, to get the system change that we're gonna need to make the apparatus and the cost of that apparatus worthwhile. How many hospitals do we need in? How many payers do we need in? What is the critical mass that we need in the model to make the apparatus that we're gonna have to put into place to manage it and to oversee it worth the expense? You know, I could see in the timeline, the hope is that you have one payer in and then you have 30% of Medicare fee for service in after a few years. To me, that doesn't feel like enough revenue in the model and enough participants in the model necessarily to make the apparatus cost effective. So those are sort of things in our analysis. What would we need to have in the model to generate the delivery system reform that we want and to make the regulatory structure that's gonna have to be put into place worthwhile? So these are just analyses that I'm hoping, I'm asking about it now and recognizing that you don't have these answers now and that this is something, this is a step two. Step one is applying, but I just wanna articulate that for me, these are the types of analyses that will help me feel confident that when it comes time to make a decision that we have all the answers to know, not all the answers, you never have all the answers, but we've done the appropriate analysis and the due diligence to say, given the information that we have now, this makes sense for Brahmadars. So I thought I would share some of those thoughts with you today in the hopes that we can continue that conversation over the next few months. Thank you, Dr. Holmes. Chair Foster, would you like me to respond to that? I get totally up to you, Pat. Any of these if you want to, please. Yeah, I'll make a couple of comments a lot there. Clearly things that we're all thinking about and yes, it's incredibly difficult when alternatives are not extensive and the questions are many. In terms of the next best alternative, well, again, we have healthcare reform efforts in our state that should be able to continue without Medicare, but there's no question that it would hurt. And our understanding of the alternatives that would be available to ensure Medicare participation are number one reversion to fee-for-service Medicare payments and number two, the model, the other model that appears to be still open is Medicare shared savings programs. So that would be Medicare only, there would be some fragmentation there in terms of alignment of reform efforts, but those are our understandings of the options. You know, in terms and the analyses that you're suggesting make all manner of sense and we will do our level best to provide whatever analyses we can. In terms of sort of some of the risks and unintended consequences, access is a key one with a model like this where you are looking, and I'm thinking not so much on the primary care side. In fact, I think what CMMI is articulating in terms of enhanced payments and increase investment in primary care actually has the potential to help access to primary care. And we haven't talked a lot today about hospital global budgets, but whenever you're looking at a payment mechanism like that where it's a set amount, you wanna make sure that you're robustly monitoring for access and so that's gonna need to be a key part of this model. Aside from what measures CM mass requires, that's a framework that we would wanna really thoughtfully craft so that we make sure that we're keeping, monitoring access. And similarly in terms of commercial insurer, coverage and affordability, that's gonna really hinge on how we construct the model with Medicare's participation so that we're getting adequate federal funds as well to help support that. System preparedness, we do have the 12 million in cooperative agreement funding. I'm not going to pretend that that's enough to get a system ready, but it does help jumpstart some of that preparedness. And we're doing a lot of work in addition there. When I think about what the agency that I work for has done in recent years around an alternative payment model for the Brattleboro Retreat, for example, looking at rates and trying to increase rates, I believe the secretary uses a number of 164 million in investments in recent years to really try and help shore up some of those areas where we know from hearing from providers that there are some challenges, mental health, home health, long-term care, skilled nursing facilities. So those efforts are ongoing, have been ongoing and will continue to try and make sure that the system is prepared to meet the needs of firm monitors. And there's been some workforce initiatives that have been implemented as well. And in terms of data, our teams work together with the data resources that we have, but we are definitely focused on and continue to be focused on the HIE. You've seen our strategic plan there, but making sure that that includes comprehensive data from a variety of sources and in a way that's usable for analysis and care. And then in the last point I'll make, you had mentioned how much fee for service revenue is needed. One of the things that CMMI asks for in the application is what are the policy levers that 10% of net patient revenue, Medicare net patient revenue under the model in year one and 30% by year four. Those are minimum amounts. We have talked in the hospital global budget technical advisory group about options for, do you start out voluntary, do you phase into a mandatory? And that applies to both hospitals and commercial insurers. And so that's something we're gonna have to the type of analysis that you're talking about really helps us ascertain whether we wanna take a more voluntary approach. And that's what we've done with the current model when we've gotten some kind of decent uptake, but is it enough to make it worth it? That's a really good question. And we do have levers at our disposal, as you said, establishing the regulatory apparatus to implement those is not an easy lift, but we do have mechanisms for working with providers and seeing if we can reach an appropriate level of participation if we decide, if we are selected and if we decide to move forward with the model. So thank you. I hope again, a bit of a cursory response, but I'm taking careful notes. So thank you. No, I appreciate it. And I didn't expect all the answers today. I was just saying these are the types of, answers over the next 15, 16 months that it would be helpful to see. So I appreciate that that they're already, of course, on your radar, you're thinking about it. And I look forward to hearing more. Thank you, Pat. I might need 15 or 16 years, but I guess we don't have that. Thank you. I took a lot of time for the last few meetings. So I'll just be brief. Thank you so much, Pat. This is a heavy lift and I think the application itself is a heavy lift and implementing the program will be also a huge heavy lift if it comes to that. So, but I think I really appreciate the diligence and hard work and communication that you have done with this. I just have a few quick questions and then I think there's a chance that we might go into executive session and I have some more questions then, but the, and maybe Robin is the person to answer the question because maybe it was Elena, the 17 p.m., p.m. in primary care, my understanding is that there's the, we come up with a medicare, we come up with a medicare total cost of care number. Then it's the 17 p.m., p.m. primary care and the blueprint in addition to that number, but that $17 p.m., p.p., p.m., last for three years and then that gets wrapped into the TCOC. Well, the $17 p.m., p.m. lasts for the whole model. The question is whether or not it counts towards the medicare total cost of care target within which we have to live or there could be like a corrective action plan or something like that. So it doesn't, the money doesn't go away, it's just whether or not it, we have to be mindful of how it impacts the TCOC or not as a state. Does that help? Yes, and so it would not affect, so after three years, would it affect an individual hospital's medicare budget? I think we don't know yet. I think we can talk about what is in the spec for medicare but I think that the state has the opportunity of proposing its own methodology. So I think depending on what the state thinks is the right way to tackle that, we could try to negotiate something. So we could go into that sort of the considerations in more detail in the executive session about the potential negotiation levers. I think that's all I have for now. I have a lot to say last time, so pass to somebody else so it doesn't get too late here. Just a couple of quick ones. So far we've sort of been at the high level of sort of the goals and here's what we're trying to do and here's what is on the table. I think getting into the substance in the meat of like how it's going to do those things and what the risks are and all of the more substantive points of how this would work, I think will be really helpful in the coming months as we evaluate this. So for example, if we talk about avoidable utilization and that's a key component of making the program work well, what utilization specifically are we talking about and where is it going and how is it getting there, right? And so for example, I mean, we hear about it all the time, the problems with hospitals discharging patients. So if we're trying to avoid ED utilization or put people in post-acute care that's appropriate, do we have that? And if we don't, what kind of risk does that create? This might be like too simplistic, but I understand the whole theory, but so you're trying to put more money to preventative care, but it's not so simple as changing the payment model and then all of a sudden you'll have the preventative care or the long-term care that you're going to need. So like a hospital can't just get rid of the orthopedic surgeons it has and add mental health and long-term care and primary care. They have people that work there that do things and just rejiggering is much more complicated. So I guess understanding sort of the risks and abilities to make these changes so that the program and model works well would be really, really helpful going forward. And then I think a lot of what member Holmes said I thought was really thoughtful in terms of like the evaluation and the analysis of what we're doing. So I've been looking at bills that we get for our contractors and I've been looking at COAG funding budgets and it's a tremendous amount of money. And I guess understanding what the financial investment is for the state to do it.  But just to do the application, to do the negotiation to then come up with a regulatory process for then like hiring contractors to track all of the total cost of care and the quality, right? Then on top of that for a hospital to be able to make the transformation, a hospital to have two budgets, a hospital to have two budget review processes, the airport to have two budget review processes, all of those expenses are quite massive and I wanna make sure we're understanding all of those. And they may be like a great investment because there are additional monies that are really important to the state here that we could get but just really understanding them on a granular level I think would be beneficial. And then also considering the scope, right? Because if we're talking about whether or not it's a mandatory program or a voluntary program or whatever it might be insurance, not insurance, all those costs are much better when they're spread out between 14 hospitals or participating with full commercial participation, right? So they might not be bearable or worth it if it's two hospitals and no commercial. They might be a really good investment if it's the entire system. And then that also goes back to my first concern or question I guess I should say which is whether or not it will work and whether risks are to it working. And if it's only one hospital with 30, 40, 50% of its money maybe it doesn't solve as much as we had hoped. So then there's an opportunity cost in that I know you Pat for sure have no capacity to work on any other really substantive reform things. I know our staff and board members don't either. So right, so we can't do other things because we're very focused on this and that might be the best thing we can do but if it ends up being a really small scale and scope it's just something to consider. I guess the last thing I would just say is that access measures, the utilization points that members Walsh and Holmes made are really important to make sure that we're not losing access and that the model works for our access issues but then the protection for commercial and how do we make sure that we don't have really huge large increases on the commercial market here in the state that we've had for the last several years and how do we protect against that in this model? So I don't have any questions if you wanna respond you can Pat, these are just kind of food for thought things to kind of keep track of as we go ahead. Thank you, Chair Foster. I'll just respond very quickly. The question about how we can address things like avoidable utilization given some of what we're seeing in the healthcare system, we've touched on this earlier but it's really a multifaceted approach where we look at what can the state do to help shore up those systems and I can assure you that we're quite focused on that. What are some of the investments coming into the system under a model like this and how can we best use them? And recognizing the longer timeframe in this model I think does show an understanding on the federal government's part that we're not gonna be able to make these changes and solve all these problems overnight but if we focus on them we can resolve them over a time period of a few years. Yes, I think we have to look at what the financial investments required would be and then your linkage of that to scale and participation levels makes a lot of sense and we have to determine whether it's something that we wanna move forward with and if so how to encourage the appropriate level of participation and then just would reinforce your last two points that access measures are going to be key and we wanna know what's happening with utilization. Sure, if there's potentially avoidable utilization are we seeing a reduction in those areas maybe partly because of improvements in the system? Are there areas where we wanna keep an eye on whether people are getting appropriate care absolutely and ensuring that we can address affordability in the commercial market is essential. So thank you. Yeah and so much of that turns on the negotiation. So you had on slide 11 you have so many of the benefits, right? And all those benefits influence reimbursements, continued recognition, low cost care, baseline recognizes past savings, all of those, not all of them, most of those turn on what we get in the negotiation. So how much return on our investment as a state we get will really hinge a lot on what that negotiation looks like I think. Absolutely, yeah. To be stating the obvious. I guess I'm starting to get stressed about that because I'm sure you are. Yeah. Okay. Well, thanks for bearing with us all afternoon here. You're really patient with us and I appreciate it a lot. No, I'm happy to be here and I'm an open door for questions. So thank you for taking the time. I'll open it up to public comment via the raise the hand function. And Owen I just wanna say that I would like to go on to executive session if we think we can save a few minutes for that. But I think it's appropriate to do that after public comment. Yeah, I didn't wanna keep people waiting. I've been patient. Ms. Wasserman. Hey, how are you? Julie, are you there? Can you hear me? Yes, I'm sorry. I just had to click on my camera and my mic. Thank you so much. Boy, long day, lots to absorb here. And I have a number of comments I'd like to contribute. As you know, I already submitted a critique of the AHEAD model to you and it went to the agency of human services as well as the governor's office. In that critique, I propose that we forego the AHEAD model. Why? Because it does not address Vermont's most pressing problems. And in my view, it will distract us from doing so. AHEAD does not address our dwindling supply of primary care physicians. People can't find a primary care physician. And it doesn't even acknowledge that or address that. I suggest that you look at PATH's last slide on primary care, what the Green Mountain Care Board's primary care advisory committee says, there's 14 or 15 items. And I suggest you look at that slide and check off the items on that slide where AHEAD will actually address the issue. AHEAD does not address affordability. It does not address access and it does not address wait times as have been addressed, people have mentioned those today. AHEAD does not address the critical lack of funding for mental health and substance use services. And AHEAD also mistakenly focuses on fee for service and volume when the actual problem appears to be hospital prices. Many people are concerned about AHEAD's global budgets locking in current and historical hospital spending. And it denies Vermont the opportunity to address arbitrary hospital prices, reference-based pricing, extraneous hospital costs and unnecessary ER utilization. And all of those areas are areas for potential savings. And those are off the table once we go with AHEAD's global budgets. And also under AHEAD's global budgets, hospitals could potentially withhold expensive care for patients who need it most. AHEAD model will dramatically increase administrative costs and complexity, something that we should be working to do the opposite. It's a very complex, convoluted model and it will be very expensive as some of you have mentioned. Regarding AHEAD's primary care investments, I'd like to suggest that the $17 million that has been discussed today needs a thorough analysis. And, you know, is the $9 million from Medicare for blueprint in or out? We need to know that sooner rather than later. I don't think we would wanna wait until negotiations. That's a pretty important piece. A third of Medicare enrollees in Vermont are in Medicare Advantage. So they're not even a part of that. I don't know if they were included in or not in the $17 million. Another point is that hospitals are saying that they are not interested in participating in the AHEAD model unless AHS oversees their budgets. So if that's the case and the Green Mountain Care Board continues to have its regulatory authorities over hospitals and also hospitals own the majority of primary care physicians, there could be a pretty low participation of a primary care physicians for that $17 PMPM. So my point is that there's a lot of variables here and that I think it's dangerous to throw around the $17 million until we have a careful analysis of that figure. In addition, we know that given the majority of Vermont's primary care physicians are worked for hospitals, what guarantee do we have that those investments won't go to the hospital's bottom line? Now, the same thing happened with OneCare and their primary care investments in 2023, 2024, and also in prior years. As we all know, there's a pending legal action, but we still don't know if that roughly, I don't know, $20 plus million directly supported primary care as it was intended or did it bolster hospital revenues. Most importantly, there is great concern that a head would in some way disenfranchise the Green Mountain Care Board by shifting oversight of hospitals budgets to the agency of human services. And also I might add the hospitals. We need to clarify where the locus of hospital budget control would be with the head model before we move much further because if a head means that the Green Mountain Care Board is disenfranchised and does not oversee hospital budgets, that would be a pretty significant piece of information to have in terms of whether or not we want to go forward. So I suggest that instead of pursuing the head model, Vermont should do a number of things. I think we have a lot of options open to us and all of them are within our purview. One would be to strengthen and fortify Vermont's primary care physician workforce through aggressive recruitment and retention initiatives. Another would be to pursue initiatives that improve affordability, improve access and improve equity. I think that we could spend a fair amount of time in Vermont focusing on initiatives that actually reduce the need for hospital care. Reduce the need for hospital care. We all know what that is. We all know that increased access to primary care, increased access to mental health services and home health all would help to reduce the need for hospital care. Furthermore, we need to immediately increase funding for mental health and substance use services. A case in point, since August, the Howard Center has closed four programs and they've suspended an additional two programs. So six programs in all. Those programs are CenterPoint, intensive family-based services, autism toddler community program, public inebriate program in St. Albans, Act One and the bridge program. Now, is that not a wake up call? I think we have to pay attention to that. And I hope AHS is aware of this because as we all know, they fund the DAs. Other ideas for ways we can move forward is to standardize hospital prices through reference-based pricing. It's a proven rate-setting method. We can develop initiatives to identify and eliminate avoidable hospital care and unnecessary ER utilization, as I've mentioned. And one other idea is hospital capital expansion. Hospital capital expansion is one of the big drivers of escalating costs. We could think about creating a statewide global budget for hospital capital expansion. So in conclusion, I think we should forego the AHEAD model, which potentially removes hospital budgets from the Green Mountain Care Board, hands them over to AHS, which I'm hearing wants the hospitals to set their own payment methodology. That's not too reassuring. And also, forego the AHEAD model, which will lock Vermont in to an untested model, untested model for nine years, nine years allowing for little to no progress on Vermont's most pressing problems. And it's apparent from today's discussion that there has not been enough analysis of what the effects of this model would do. In fact, it's woefully inadequate. And I think in order to move forward, we need some analyses as member of Holmes suggested. But one of the biggest problems of all of this is that there has been no public process on the AHEAD model. In my mind, it's a bit of a travesty to be locked in to an untested model for nine years without a public process to vet the merits of this initiative. Legislators have no idea what AHEAD is. The public who we're supposed to be serving has no clue. And even people in healthcare don't know about this nine year initiative. So I'd like to conclude by saying that we needed to initiate a public process with all the affected parties, especially Vermonters and the AHEAD model needs to be fully vetted in the public arena. Thank you. Thank you very much, Ms. Wasserman. Mr. Flood. Good afternoon, Chair Foster. Can you hear me all right? We can, yes. You can. We can hear you. I am having a little computer problem. If the connection's not good, I'll shut off my video. But I want to add my voice to those that are concerned, very concerned about proceeding with this model. I have to agree with what Member Walsh said earlier that this model is not tightly aligned with what Vermont really needs. And I think that's absolutely true. This, to me, is just another very complicated, very expensive model that will take up all our time and energy and we will not get to dealing with the issues that really need to be dealt with. There's no mention, really. There's no significant mention in all of this of mental health. There's no significant mention of long-term care. There's no significant mention of services like home health. And without those services being robust, all the focus on primary care in the world is not going to change our health care system. And I believe it was Member Holm who pointed this out that if ours can refer to effective services, then what have we accomplished? Now, the $17 per member per month is very seductive. And in fact, it could be really helpful because it's one of the things that we know primary care needs. We know primary care needs. But we also know from what the doctors tell us, that primary care needs are relief from the administrative burden. I see no attention to that in this model. We know that primary care, as I just said, needs referrals to effective services in the community. I see no addressing of that in this model. There is reference to making referrals, but it doesn't do you any good if there's nobody to refer you to. And I think that probably all of you saw the recent letter from four emergency room doctors who were pointing out just how bad boarding has become in our hospitals because we don't have services to discharge people to. And in fact, we don't have nurses on floors enough to discharge people upstairs. That's how bad our system is getting. And this model is not gonna solve those problems. And in fact, what's gonna do is distract us. Primary care has never been the problem in our healthcare system. It's never been the issue. The issue, as I think most of you actually know, is hospital costs. I heard earlier about hospital pricing. It's, if we don't, I don't see anything in this model that's actually gonna deal with hospital, across our hospital pricing. We know how to do it. As you really just mentioned, there are techniques we can use to do that. This model doesn't address it, in my opinion. I haven't seen enough evidence to it. And the whole avoidable care problem is not addressed. It doesn't even come up. The term avoidable care is not mentioned in any of this. I have to comment that I appreciate the effort the board made in the past year or so to address hospital costs. And I find it very ironic that the thank you you got for that was a bill in the legislature that was gonna teach you to be decorous. It's pretty ridiculous. We are focusing in the wrong area. We know what to do and we're simply not doing it. So what I would like to ask the framers of this model is for specific measurable outcomes. Don't tell me that medical care is gonna give us $17 a member per month. Tell me what we're gonna accomplish by that. Before you approve this model, I think you should ask them for measurable outcomes. For example, like, how many more doctors are we gonna have in this state? And by when? How many people in the state are gonna have access to a primary care physician when they need it and by when? I don't see anything like that. How many people in this state are gonna have ready access to a highly affordable mental health care? But I don't think you're gonna get answers to those questions because I don't think the framers of this model have even thought about it. But we need some kind of measurable outcomes here or I