Good afternoon, everyone. My name is Kevin Mullen, Chair of the Greenmount Care Board. We are going to get started this afternoon. And the first thing I'm going to do is have the board members introduce themselves in alphabetical order. Sorry, I had to find my lens. So my name is Jessica Holmes, and I've been on the board for six years, and I'm an economist, and I teach at Middlebury College as well. Hi, I'm Robin Lange. I've been on the board for four years. I'm a lawyer by training and also a health policy person. And I am my previous roles. I worked in a number of different areas in state government. Hello, my name is Tom Pellum, and I've been on the board almost three years. And I was born and raised in Arlington, Vermont, and I was the state's finance commissioner for a number of years and the state's tax commissioner for a number of years. Hi, my name is Maureen Youssefer. I've been on the board a little over three years, about three and a half years. And my background is corporate finance, CFO and public and private companies. Thank you, board members. The purpose of this afternoon's meeting is not about hospital budgets, surprise. And what we're talking about relates to the all pair model and the ACO. And in August, I believe it was the 11th, we received a copy of a letter from Susan Redston. And we're going to hear from her this afternoon, as well as Vicki Loner from one year of Vermont. And as we all know, foundational to success in the all pair model is an emphasis on primary care. And also it's very important that everybody's rowing in the same direction as we try to accomplish key goals in Vermont. And so this thing is kind of blown up a little bit and what it basically and I'm going to turn it over to Elena to walk everybody through this. But basically what we're talking about is a change in the per member per month payment that it was given to docs as they participate in different programs. And it may not have occurred, but just my initial thoughts are that there may have been a communication failure in the discussion on this and people may not have been talking directly to each other. And hopefully today we can get everybody rowing in that same direction and everybody working towards achieving the goals that we have in Vermont to move away from fee for service to a value based system that really will help for monitors have a sustainable health care system. So with that I'm going to turn it over to Elena and she's going to walk us through where we're at and then we're going to hear from Vicki and any members of her team that she has and from Susan and any members of her team that she has and with the with the idea that hopefully we can facilitate a really good conversation and get everyone working together so Elena if you could take it over. Yeah, happy to me I'm just going to kick us off so I'll try to keep it brief and let you guys do most of the most of the work today. Can you see my screen. We can. Okay. So Elena Berry be director of health systems policy. You know I think Kevin kind of gave us a nice introduction but I'll kind of reiterate a couple things so we'll talk about the goals of today's discussion some background staff observations, and then allow you know board discussion with both Vicki and Susan from one. So, you know the board invited here today to just ask everybody who's not speaking to mute themselves because we're getting some feedback from Elena. All right, try to keep going. So, we're here today to discuss the changes to one cares primary care payment reform program and address the goals of this primary care program, or programs are there multiple how these programs align with the overarching goals of the all pair and then obstacles for each party and the potential resolution for 2021 if we can. So, you know just some background so the green on care board overseas and approves ACO budgets annually. So normally this conversation would happen through that process but because the legislature is kind of focusing on it and it's come to our understanding that you know there are some opportunities here to kind of flesh out you know it. It came to the board kind of premature from our standard process. You know but just to give you some background in 2018 and one cares budget review the board order the ACO to create a program to encourage independent providers to participate in the all pair model through the ACO program that came out of that was the comprehensive payment reform or CPR pilot program. So that is just one piece of the many population health and other payment reform programs available to to independent primary care providers. You know I think Kevin you kind of went through this I won't spend much time here but you know this first came to the board's attention and health first letter to one care on April 11. I believe GMCB staff really ushered leadership on both sides to try to find a path forward. And then there was the letter from one care to health first dated August 25. So hopefully, all of you have had a chance to read those letters to understand some of the key arguments on both sides. And it helps to kind of understand what exactly it is we're talking about and I just want to recognize you know Vicki and her team have been putting together something similar I believe in response to legislative requests. But this was my attempt to kind of kind of explain what you know how these different programs work together and where the differences are so in 2020. And for all primary care providers, you could adopt, you know, if you were hospital owned your choices fee for service or fixed perspective payment. If you're, you know, independent primary care provider, you could opt into the CPR program which is a fixed or capitated payment. And that was to kind of, you know, as Kevin mentioned before, migrate from fee for service to fix perspective payment those are kind of those two buckets so provider reimbursement for services. And one of that their population health management investments. And that was the 325 pm pm. That was across all payers in previous years. And then there was the CPR population health investment which was additional which is another $5 pm pm for participating in that program. So in 2021, you know, we still have the same options as it relates to the reimbursement process for primary care providers, but the change that that's been in discussion to date is really about the population health investment. So, you know, the 325 pm pm. That was existing across payers at the time. So it kind of broke out and, and became a little bit more nuanced I think five payer program so in the Blue Cross Blue Shield QHP, as well as the large group risk based program. So, you know, I think that's the scale target qualifying there also a piece of that that program that's non scale target qualifying that's in that second box that you'll see as well as Medicare and Medicaid. You'll get the 175 base pm pm plus a 3% pm pm contingent on ACO performance so that brings you to the 475 that's been cited by one care. Alternatively for MVP and Blue Cross Blue Shield large group non risk so that there should be an ASO in that box I'll fix that. I'll just set 325 pm pm no no contingencies and then the CPR population health investment again is still additional there have been no changes to that program $5 pm pm. So I'll keep going and I'll let you know Vicki answer the more precise questions about the program changes this is kind of the extent of staff knowledge at this point but we hope to learn more very soon. Another thing to recognize, you know, is the work that's happening in the legislature they've crafted some language, and we provided some feedback without making kind of a recommendation as to whether or not we support or kind of don't support the language but if they move forward there are some things that they should keep in mind. One is to is to move the language which is currently in the certification section to the budget review ACO budget review section, which would be more in line with our staff review of one year payment reform programs. In addition there was some confusing language describing the provider payments which we kind of went through in the previous slide and I think there's still some work there and I understand they're still working on it and have been discussing this morning so you know we'll keep you in the loop as that progresses. So just some basic staff observations about the conversation about these programs to date. I think we just want to recognize that this is a really challenging topic and there's no obvious solution, but we recognize the tension and challenge of designing these payment models for primary care that balances you know these sometimes competing objectives so you know increased investment to support greater access to primary care predictability of payments that allows planned upfront investments and preventative services, mutual accountability across the continuum of care that incentivizes collaboration among all kinds of providers whether you're in the same organization or not. Risk sharing that facilitates adequate skin in the game to support desired changes across delivery system and then provider led incentives that drive improved quality and population health outcomes, as well as greater provider participation at scale so these are all very ambitious goals. I'm sure there are others but these are things that we often think about when we think about designing payment reform models for primary care providers. So some next steps I you know want to recognize that this should be a board led conversation but some questions that staff have identified and that have been kind of circulating in the general sphere. We wanted to kind of give you a flavor for what we've been we've been wondering and you know so what problems do the 2021 primary care program changes attempt to solve so I think you know there's a big emphasis on accountability but one of the questions is accountable for what. You know I think you know we really need to understand like what was the impetus for this change to really understand kind of get behind this this evolution. How do one cares primary care programs design support the goals they all pair model including improving quality and population health outcomes as well as increasing scale. So you know we need to make sure not only that these these programs are doing what they're designed to do but that people are willing to participate in them that's important. So why don't we see more independent primary care providers joining the CPR program my understanding anecdotally is there's perhaps one additional participant but you know hopefully there's some good news coming around the corner but you know we really don't have that budget submission yet so. It's hard to say what it will look like for 21 but over the years we you know it's it's been an opportunity. Our one cares population health management primary care programs expected to be transitional. To the CPR program or some kind of capitated program or are they you know what are they on ramping to and it would be helpful to know kind of the strategic plan for for those programs. Aside from mutual accountability structure are there other ways to increase collaboration across the continuum of care if that is one of the sticking points. And it appears that these 2021 program changes lacked adequate stakeholder input which we've heard over and over again but while we're hopeful that one care and health first can come together you know how can we make sure that we don't end up here again and and kind of facilitating an open conversation and continue especially if this is going to evolve making sure that we're all we're all working together for the same goals as Kevin mentioned earlier. So I'll pause there and I'll open it back up for the board members to facilitate me. Unless you have any questions for me but I'm not the expert. So it might be helpful. If we before we start getting into questions if we could hear from Vicki with the process and her attempts to answer some of those questions and then hear from Susan and then I think the board would have a much broader picture and can begin asking some more probative questions so Vicki do you do you mind leading off here and giving us some background talk about how the change was made and why and what you see as the benefits of the change and is there a way that we can bring these independence on board in a way that you know is a goal of everyone so why don't you start and then we'll listen to Susan afterwards. Yeah that sounds great so for the record Vicki loner CEO one care Vermont. Elena is there any way you could bring up the PowerPoint that I had sent earlier just so when we get into the program details I can. Yes, I will pull that up. Awesome. Thank you so much. So I think that you're all familiar with the overall goals of the all payer model and more specifically for an ACO our charge has been to reduce or mitigate costs health care costs so that it can be affordable to donors while maintaining or exceeding certain health care quality goals and there are those very lofty population health goals that apply to the whole state and then underneath those there are health care delivery system goals that we have to meet as an ACO. So everything that we are doing is to support the goals of the all payer model to reduce costs to make it more affordable because we know it's not affordable and sustainable in its current state and at the same time maintaining or at least improving I think the real goal is improving those those quality goals and part of that is getting the system to work together as a system. This is not something that fee for service has traditionally supported it supports people working in silos within their organization because there isn't a shared incentive as part of that. So that's the second piece of it is how do you create a shared financial incentive and when we look at our programs and how to develop and evolve them. We're always looking for what are those shared incentives that we can have so that the system can start working together in new and different ways and it has the capacity to be able to do that and work in those new and different ways. When one care first started its programs in 2017. So now we're year four right now. A lot of our payments were geared towards capacity payments to help people to at least participate in health care reform activities and those capacity payments were on top of existing revenue that the providers would get from from the payers. So this is always additive when you're talking about one care programs and it doesn't impact their current revenues. So we developed a series of incentives for providers to be able to participate. I think you know them all well. There is care coordination which is an eight to ten million dollar budget line every year. There's a population health management payments as scale has increased. So is that dollar amount were up to probably nine million dollars for next year just in that one payment alone. We have the value based incentive fund that also rewards for quality. So that was the initial on ramp or the glide path to how do we get the system to start working differently and having some resources and capacity to be able to do that. We are going into year four of a five year demonstration grant. And we have to be able to show the federal government that we can be accountable both clinically and financially for the lives that are underneath this type of model which is really moving away from fee for service to value based care. So that's the bottom line is that what by year five we have to show that we can reduce costs increase quality and together working together be accountable for the overall costs of care. And I think that's very much in line with what we're trying to do not to say that this isn't disruptive. This is a very disruptive change to the traditional fee for service. And if you look at the opportunities under this model and that's what I want to go through. I think making this change now actually opens up way more opportunity than just sticking with that capacity payment for us to do better together. Up to this point in time we have not provided any shared savings opportunity for primary care if we do better as a system. Next year we will be providing additional incentive for primary care as long as we all do well and that's the goal of the model. I'll have to work better together to improve those goals. So I wanted to take a second to just walk through what that might look like. Elena can you go to the bar graphs. Yeah. Thank you. Is there. Thank you. Could you make them big a little bit bigger. Thank you. So I thought it would be helpful. I always find having a visual very helpful to say OK what would the world look like without an ACO in it. And that's that non one care bar. So those are individuals practitioners that are practicing in Vermont but not in a one care program. So they're receiving their traditional revenues from the payers as is. And you know there there might be some other funding that they receive but it's not through the all payer ACO model. And as you move from the top down what you're seeing is an increase in the amount of the movement away from fee for service to value based care. So in the first bar you have people just I think about it as getting your toe in the water with health care reform efforts because you're still receiving those fee for service incomes. That's that twenty five dollar line. But you're also receiving some additional revenues on top of that twenty five dollars which is not fixed. Right. This is variable based on billed services. And when you add all these PM PMs up even if the ACO does not do well which is not sustainable by the way you still would have an additional 17 percent in your PM PMs for your revenues on top of that. And this is something that's available to all primary care. So FQHC's independence. We can't really say that the hospital primary care are in this particular program because their payment their revenues are fixed but they do get these additional enhancements on top of that. Then we move down to the we call it the conventional model. So again receiving those fee for service revenues from the payers receiving all these additional enhancements on top of that. And the new thing this year is that we're still keeping a P H M payment in place. It's moved to from three twenty five down to one seventy five. But if the ACO at least meets its budget. So the ACO gets a target that's set by the payer. If we meet the payers targets that one seventy five gets brought up to three twenty five. If the ACO actually saves money then that three twenty five gets brought up to four seventy five. And that is additive to what has happened in previous years before it would stay at that three twenty five even if the ACO did well. So this is the what I say is the opportunity that while increasing accountability you're also increasing the opportunity to receive additional funding under this model. And then the last two bars are the programs that are specifically developed with independence in mind and that's called the comprehensive payment reform model. So that twenty five dollars that's normally variable and subject to how many claims you bill becomes fixed. What we saw during the pandemic that that that fixed payment was instrumental in many of the practices continuing to be able to keep their doors open. When we look at the forecast of what that meant in dollar amounts to independent practices that were in and there's seven practices right now. It's a little less than a million dollars a year in additional revenues that they had that they have because of this model. And then on top of that fixed predictable payment we also have all the incentives that are built into the conventional model plus a five dollar PM PM incentive to enable practices to be able to make that lead to a truly kind of fixed predictable income model. And even if there's not shared savings you can see underneath this model that they still do much better than those that are in the conventional models with or without shared savings. And as you move down if we do as an ACO system of care received shared savings there's an opportunity to do even better under this type of bottom. And I do want to emphasize that if the ACO received shared savings first dollar of that savings goes to primary care. It does not go to the hospitals that goes to primary care. So I think that's an important understanding is primary care is getting the first bite of any of those savings that occur at the ACO level. Are there questions about the model that was a lot to take in but I just want to make sure that it's clear about what the program of payments looks like for next year as we've built those through our committees. Questions from any board members. Well we'll assume that all four of you are scholars on this and you'll be able to pass the test later today. Okay, that's great. And I have a question. Oh, I'm sorry. This is Elena. I'm just wondering so so there is a potential for in some of these situations for providers to be kind of in the same position as if they were not participating. So if there's no if there's no shared savings and they could effectively be accessing the same amount of money that they would be participating. Okay, so I guess are there other opportunities then because it'd be hard I think to find investment money to invest in population How would you how do you navigate that challenge so if providers are supposed to be investing in prevention and additional services to make population health work but they're not sure if they can access those funds up front. How does that work or are there other ways other dollars available to them to do that. I think that's what all those additional bars are Elena so the $1.75 the $2 in the care management. The 41 cents per member per month and the value based incentive fund which we're looking to move closer to the calendar year instead of having to wait. I think that would be helpful I think to delineate a bar chart in that way to see like what what money is not moving versus what money is subject to AC a wide performance because then I think we can get a better understanding of what dollars are actually available to kind of move the needle in population health. Yeah, the money that's the shared savings is the $3 bar and so there's a $1.50 of that bar if you at least know how to do that. Right that are based on the payers. So we just have to at least break even and then there's another $1.50 available if the AC a wide performance. If you meet the ACO targets right that are based on the payers. So we just have to at least break even. And then there's another $1.50 available if the ACO meets. So that's why we wanted to show. Okay, if you had no shared savings at all, you'd still have 17% extra to invest in population health management. If you're on a traditional program. If you're on a CPR program you have 37% of your base PM for investment. So the second and third bar if you're starting at the top are really the same program but two different scenarios and the left the bottom bars are the same program with two different scenarios. So if you're with or without shared savings so that you can see even if there's not shared saving there's still investment that's being made but there's more opportunity if we have shared savings. So Vicki, you know what when you look at this it sounds like the CPR model really offers the best opportunity for independent primary care providers. Why isn't there more uptake. You know I think in the beginning Kevin it was new and anything new as you know comes with a lot of bumps and bruises along the way. So you have to have some pioneers that are willing to say, Okay, I'm not going to worry about fee for service anymore. I'm going to go to this fixed payment. So I think that's been the major challenges people are used to receiving fee for service so moving from fee for service to fixed payment is a very different approach. And at the same time I think we've heard from our federal partners and CMS Seema Verma just kind of issued a notice that said they're going to double down on moving away from fee for service and to a value based system of care and I think when they're going to double down they're not going to provide additional incentives that maybe then you get less of an incentive they're going to double down on your revenues, which is a very different approach than what we're taking here. And what we've seen during the pandemic is because it's been very predictable we have seen I think we have two additional practices right now that are going to be signing up for next year. Vicki can I just ask build on Kevin's question which is how are you promoting it. I mean, you know, particularly given the pandemic and as you said the fixed payment was so instrumental in, you know, the solvency of those independent providers that were participating. What kind of outreach efforts are you making. What is the messaging to try and encourage more independent providers to get into the CPR model. Yeah, that's a great question. We've been actively working on that I have personally reached out and Susan can attest to this to every association leader of primary care to let them know what the benefit plans look like for next year, including the CPR program. The staff at one care have made personal outreach to every single independent practice that is currently participating one care right now. And for those, you know, to talk about the program and for those that have been interested we posted to our portal, probably two to three weeks ago, what their payment structure would look like under our fixed perspective payment. With these additional incentives built in for them. It's changed a little bit the CPR and that we used to just build all these additional incentives into the CPR program but then it became complicated for providers to figure out like what's my fixed payment versus which is the incentive. So we're just having it straight like here's your fixed payment with the $5 built in and here's the extra incentives on top of it. I also have a follow up slightly differently so. Vicki, you mentioned the recent announcement about moving to value based payment and I was wondering on the non one care slide it doesn't really reflect, for example, the current value based payment structures in Medicare with MIPS, which is 9% upside or upside risk in the underlying fee for service payments so I don't know kind of what's been happening with MIPS in Vermont out and you may not either since that is not people in the ACO aren't subject to that but if you had any thoughts on that. I'd love to understand more. I actually, I'm glad you asked that question Robin. I think that one of the benefits that we tried to lay out just briefly up on the top of it was that if you're participating in one care because of the all pair model arrangement were considered, you know, an advanced payment model. And so practitioners that are in it. They don't have to submit their own data the data is submitted through the ACO quality measures, and there's an automatic 5% bump. So it's not based on performance there's an automatic 5% bump. And interestingly enough what I've heard, or what I understand is that 5% bump is on all part B claims and not just the ones associated with ACO attribution. So, we are told by Fatima that for 2018 because that was the first year we were in Medicare, those dollars amounts will be released later in 2020 and we'll be able to tell what value that brought to for monitors but I do think to your very good point. That's a very nice incentive that was developed as part of the all pair model agreement probably thank you Robin for that. Other questions. Yeah, actually I have a couple. So, you know, we're going to hear from health first in a short while, but I'm wondering Vicki if you can talk a little bit about the reaction that you've had from say the FQHCs or other independent providers that may or may not be in health first or have you had, you know, what the uptake so far I know you have until September 11th right they have a couple more days but I guess I would just love to hear a broader perspective on the reaction to this and also the stakeholder engagement process that you went about as we're thinking about this program. Yeah, yeah, sure. As I said Jessica we have made outreach to all the primary care including the FQHCs FQHC associations and the, you know, hospital medical boards because they're impacted by this change as well so this changes across all primary care. And I would say that, you know, although nobody likes change. People, people understand why this change is necessary because we are going into year four of a demonstration grant and this is a very small move in that direction. So what we've committed to everybody on the call is that this is a one year implementation our program of payments change every year. We will be providing some new tools to give to the network to be able to monitor their performance along the year, so that they know how they're tracking in each of the individual programs because remember this is specific. So Medicaid Medicare commercial right is program specific. And we have also said let's stand up a primary care committee to be able to look and evaluate this and you know make any corrective course action as needed because I think what I hope we've shown or proven during this pandemic is that we are willing to change policy decisions because of the impacts of the pandemic right we can't control the pandemic, but we can control our reaction to the pandemic. So same thing with this year when we you know provided over $2 million in cash flow to primary care practitioners. We relaxed a lot of the policy and reporting requirements this year. If we should, God forbid find ourselves in this situation again, moving into next year. I do believe that we will be responsible and respond accordingly. And that's my commitment that I personally made to all primary care FQHC's and others. I would say the interesting thing that we've heard from some providers is that they're actually excited to be able to have the opportunity to receive additional funding based on their performance. And I know there's been some criticism to say well I can't control the ACO's performance. And what I would say to that is that this is a systems approach to improving care. It's it's not an individual practice to improving care so that's our charge population health management. It's actually a better opportunity when you're talking large numbers and how that shakes out and you know Jessica more than anybody. Then there is just looking at a small practice that you might you know have an individual in there that gets sick right and really escalate your overall total cost of care or quality. So taking this more system wide approach there is opportunity more so for them. And when we were rolling this out we took a look at OK we looked at our past performance. Is this is it really fair to say that this is an opportunity. Right. And it is from our past performance we can say that primary care will at least receive the three twenty five. But for the most part net net it would be more than the three twenty five moving forward as long as we continue to perform. And I think that's one of the things is if we don't continue to perform and be able to live within our shared savings within the five years all of this investment and as they call it call the experiment goes away. And that's not a cliff. I think any one of us wants to fall off from. So what you said I think was really just important in your financial modeling when you kind of put a probability around the idea of you know how much primary care providers can expect to get some sort of expected value. If the ACO performs as it has been then it sounds to me like the primary care provider should at least get the three twenty five is that what you said potentially more. Potentially more but probability wise they should at least get what they've had unless for some reason the ACO performs worse than it has in the past. Yes. That's really important. I was going to ask you about that probability modeling but you just answered it so I thank you. I think those are my questions. Great. Questions from other members of the board. I don't have a question necessarily I do have an observation and my the interactions I've had within you with the independent providers and specialists and I get the sense that there's a feeling out there that they're a vulnerable population and kind of on the wane and that any vulnerable population is more sensitive to change especially relative to their peers like hospitals that have deeper pockets and a deeper bench. And so you know and I think there's some basis in my observation for that feeling on the part of many independence and I'll just cover a couple of them. When I first came on the board Kevin and I read a budget hearing and Sharon got with who from rehab Jim came and started complaining that the UVM physical therapists were part of one care but the independence were. And I was told that that wasn't true that no physical therapist was part of one care at that point in time. And but then I went on the UVM website and went through all of the physical therapist and then looked at the provider list in the one care file and every single UVM physical therapist was on the one care provider list. So that kind of and there's a big article in seven days about that. I think when we go through rate setting process. You know that's a very kind of hospital centric process. And I think that you know independence kind of feel like a side car there. So in the example of that is the letter. I mean that Susan sent us just recently saying that we've gone to a rate setting process. We've increased rates and the independent providers are getting letters from Blue Cross Blue Shield that they're being flatlined that there that there is no increase for them. I think the hospital process itself as we can see we're in the middle of it is very hospital centric. And there are people that deeper bench shows in terms of boss and others that you know who were involved. So, you know, I just, you know, I just, you know, feel that you know that that independence are a vulnerable population I've come to the conclusion that to some extent they are and that an extra effort needs to be made to make sure that they are under the tent or in the tent and feel like they're in the tent. That's just my observation. I think I hear what you're saying. And, you know, that's why we created the comprehensive payment reform pilot because we do understand that they are a very different population with a very different business model than other primary care. And, you know, I think that I don't want to confound that the problem the ACO is trying to solve is that health care costs too much. And our current system is not sustainable. Right. And the quality piece of it, the rate setting is something that's not currently within one carers per view and I think could be taken up at with other levers that would be available by the state. So, I don't disagree with that. I'm just saying it's not a lever for the ACO to pull right now or that they can pull. But I think you might understand though how if you're at the end of the pipeline and you see we go through a rate setting process and I'm not putting this on one carers lap. But we go through a rate setting process and Blue Cross Blue Shield gets a 4.2% increase and MVP gets a 2.7% increase. And you're at the other end of the pipe, you're an independent provider and the result of that, you're flatlined and you're flatlined the year before and you flatlined the year before it. It doesn't pass. You know, yeah, that's hard to rationalize I think if you're an independent provider. Yeah, I don't disagree and I would say that that would be a good conversation to have with the payers in the state. Other comments or questions from the board. I have one, maybe one more, but I'm not sure if Robin or Maureen have anything. Take my turn. You go ahead, Jess. I'm kind of holding I want to hear Susan before I jump into any more questions. Okay, I guess, you know, as I'm thinking about this and it relates a little bit to Tom's point, Vicki, it's really tricky, I'm sure to balance scale goals and accountability goals. Right. I mean, the more stringent that you make the accountability, the more reluctant some providers are going to be to participate, particularly those that are the most financially vulnerable. We saw that in the hospital budget hearings with the smaller hospitals who are more financially vulnerable than the larger ones. And similarly, I think independence to Tom's point are financially vulnerable. You know, in this particularly in this COVID time. So I guess I'm just a little bit wondering if you can talk about the timing of this and also the that balance. How does the ACO try and balance, you know, what is the priority? Is the priority accountability or is the priority achieving scale and getting more people as you know, I think you said under the tent. Maybe that was Tom's words. In my mind, there's sort of an order of operations.  But without scale, you're not going to see the delivery reform. So going to the accountability somewhat seems problematic to me. So I'm just wondering if you could just speak a little bit to that. It's a bigger 40,000 foot question, but how do you balance scale and accountability in your design of your programs, you know, balancing the desire to attract providers into the program with then the accountability piece that will help savings to the system. Yeah, it's a great question. I would say from my perspective. Jessica, you have to have accountability piece because if people don't want to be accountable for the cost and quality, your outcomes probably aren't going to be that good. So if you have more and more providers, even if you have bigger numbers that aren't accepting of that accountability, you're not going to be successful. And I think the urgency behind this to start this next year is we're in year four of a five year agreement. And this is one small step in looking at accountability, actually not doing it in a way that is a pure, it's not a stick, right? So we're saying to primary care, if we do well, you will do better than you did before under this model and we've done the modeling and we can say that we feel fairly confident you will do better. And remember, this is only for those programs where there's financial risk being borne by the ACO. So the MVP program as a shared savings, as Alina said, you know, there might be a high probability that the blue cross blue shield ASO moves to a shared savings type program next year. And we have our non risk program for the blue cross blue shield as well. And so there is like half and half, right? We haven't moved the whole thing. We've only moved a portion where it requires us as a system to be able to meet our targets. There's no shared savings. And if there's no shared savings, there's no ability to reinvest in the system. So I understand why scale is important. I talk about scale all the time. But at the same time, you have to be accountable and as a system together and that requires working differently together. And I get it's it's disruptive. It's scary. I think for everybody. But as I said before, I think the way that CMS is doing a lot of this is putting those, tying those dollars to current revenue, not tying those dollars to enhanced revenues. That's the difference in what the CMS model might look like versus a one care model. Okay. Thank you. So, Vicki, before I turn this over to suits and I'm still struggling to understand. Could you walk us through what the process was like developing these programs and where independence allowed to participate in the development of and then once you determined these new scenarios, what type of outreach was done to meet with those standards so that they could understand there and help them in their decision making process. This followed the traditional one care route in terms of decision making for any of our program of payments. So all of our policies that go in our contract all our program was a payment that go into contracts go through various boards and committees. So we have a population health strategy committee that has a diversity of providers on it, including independent primary care. We have finance committees, which do include independent primary care. Our boards as well. Is there consensus on things like this? No, there's not consensus on making this type of change, but the majority of participants on these committees agreed to move forward with this. And so once the decision is made, part of that decision was, okay, this is a movement towards accountability and let's make sure that we monitor it to make sure that there's not any negative outcomes as a result of this. So let's put this new primary care group together. Let's make sure that we develop better tools and resources and that means we're probably going to have to put some pressure on some of the payers to get data more quickly and reliably to move things forward. And then as I said, the staff at One Care personally made phone calls to every single practitioner to talk to them about these changes and to show them what it might mean for them and shared with them the program of payments. And I can't say that, you know, everybody is wildly excited about it. I mean, obviously we're having this conversation here today. So there are, you know, are some practitioners that are not happy about this change. And I think what we've been saying all along is, you know, we understand we're in the middle of a pandemic and we're not sure whether or not we're going to flatten out. So let's keep, you know, this is the program of payment for next year, but we'll continue to monitor it. And if there does have a, you know, negative impact because of COVID, we'll do what we did this year. Okay. Any other questions from board members before I turn it over to Susan? Hearing none. Lena, maybe you could pull down that screen. And Susan, if you could just introduce yourself and let us hear what your concerns are and what we can try to help facilitate as far as getting everybody working in the same direction. So whenever you're ready. Great. Thanks, Chair Mullen. My name is Susan Ridson. I'm the Executive Director of Health First Independent Practice Association. Great discussion so far. I just want to level set and first say that, you know, I recognize the challenges in health care reform. Independent practices, by and large, are in favor of health care reform, payment reform. We've actually been leaders in this area ourselves having the first Medicare ACO in the state.  So it's not a matter of not wanting to enter into disruptive engagements. We do, we're willing, but they need to make sense. And I think we can all agree that, you know, we've talked multiple times about how a strong primary care foundation is necessary for a cost effective system. And it's also been shown that increased investments in primary care spending decreases overall health care expenditures and improves outcomes. And I think many of us can agree that primary care is reimbursed too low for their bedrock role in the system. This is particularly true of independent primary care who get paid less for performing the same services. So, you know, we can look at all these different, you know, charts and things about what the programs pay primary care. And I will say that, yes, one care has set up some programs that for many, though not all of our practices is an advantage over straight free for service. And so I definitely acknowledge that. However, Tim Ash said at best yesterday, you know, the, while these programs and payments are touted as generous additions. They're really just small steps toward restoration of what's been traditionally underpaid or even not paid at all for the services that these primary care work courses do every day. So, you know, we're talking about basically your cutting and already underfunded primary care reimbursements. And that's really the gist of it. And if you look at the difference that 325 to 175 we're talking 2.5 million dollars.  Is that worth disrupting the primary care system that is the backbone to everything we're trying to achieve in health care reform and jeopardizing also just our progress on the all payer model. And that to me is what it comes down to. So, Susan, if I'm understanding this correctly, if the independent doctors choose to not participate, they would even see less of a reimbursement. Isn't that correct? It does depend on the practice type. So it's not a one size fits all situation. They have to do analysis of their, you know, financials and so forth. For example, the CPR model. Many practices do quite well on it. Some are neutral. Some, though, when they look at their projections, they would actually lose money. That model also is not aligned. Can you help us understand that? Well, it depends. Like if you have a practice that, you know, justifiably so tries to do as much as they can in the primary care office. You know, removing moles and doing joint injections and staying open, you know, after hours and things, that's not really incentivized in the CPR prepayments. So, you know, the practice is somewhat incentivized to refer out to specialists. Why should they take the time to do that? So, you know, it really depends on how the practice operates and how they like to do. They like to bring patients a lot and do, you know, as many services they can for their patients or they more of a practice that refers out more already. That sort of thing. So it's just not a one size fits all. It can be good for some, but it's not. It's not for everyone. And, you know, we have to ask ourselves, is it incentivizing what we really want to incentivize? And the answer may be a combination of fee for service and a capitated model. But, you know, getting back to the point, though, you know, primary care is underfunded to begin with. Yeah, I don't think we're going to solve that problem today, but hopefully we can try to focus on the problem that's in front of us. Well, okay, so can we go back then to the cut, the 325 to 175? Vicki has stated that the projections show that it's likely that they'll actually get the 325. If that's the case, why not if the practice is the 325 that they desperately need, particularly now during the pandemic, and then, you know, have the shared savings be above that to the 475? I mean, that would just be so much easier or better for our practices who need reliable, steady income. They cannot handle any more unpredictability. And Vicki, what do you say to that question? Yeah, I get off mute. I would say it goes back to the basic premise. And I hear what you're saying, Susan, in terms of the reimbursement. But as I said earlier, that's not a problem that one care can solve. So we're looking at what are the opportunities that can be created under healthcare reform and actually moving people off from fee for service to create better experience and outcomes. And so all of that was taken into consideration when we were developing these models. And, you know, certainly, if a practice had some hardship along along the way, we'd be willing to have a conversation with them about it. It just seems short-sighted to for two and a half million dollars, which is a minuscule drop in the bucket to the overall ACO, but a huge drop in the buckets of our practices to, you know, make that be the sticking point. It means so much to our practices and very little to the overall system. And we need these practices to help us reduce costs, to help us improve quality. And these are some of the lowest sites of care that our system has. We, you know, we need to make sure that they remain viable. And cutting their payments is not the way to do it. So while you're talking about viability, Susan, can you give us an idea? And this is kind of off topic. But once you mentioned that word, it popped into my head the question. Have your members sought out the CRF dollars from AHS? And what do they say about that process? Do they feel like they're going to get help there? I don't have a close pulse on that. I do know many of our practices did apply. I have not heard that anyone has received funding yet. But certainly they are applying. Yes. Okay. Questions from the board? I just had one on, I thought when you started out Susan, you said that many, but not all the practice, this may be advantage. Did I mishear that?  You mean the one care options would be better? You know, some, many, many of the practices do benefit from being part of the one care program. There's no question. But it's not across the board. Some might lose money. Some are neutral. But some do do better. Okay. All right. Thanks. I just want to remind everybody that the chat function isn't a way to offer public comment. We will ask for public comment after we hear from the people testifying today. And that's everyone's opportunity to do their public comment. So if people could refrain from using the chat function is just kind of a distraction at this point. Other questions of Susan from the board? Yeah, this is Robin. I had a question, Susan, about whether or not you have any sense from your members who aren't part of one care, what they're seeing in terms of the impact of MIPS for their Medicare revenues? It's a good question. My knowledge on the MIPS is more in line with 2018 when I was more involved with that. Sure. And many of our practices did do MIPS then because they weren't in the ACO. And at that time, even though CMS claims that, you know, the upside is 9%, the program needs to be budget neutral. So even the highest performers in 2018, I believe got like a 1% increase. So, you know, the benefits of being in an all payer model are potentially, you know, much greater than doing MIPS on your own and, you know, having to be budget neutral on the incentives. Thanks. We don't often get much opportunity to hear about that part of the system. So it's just full time to have at least a little understanding of what might be happening. The other, I may have other questions later, but the other thing I just wanted to mention is that when we did our report to the legislature in 2017, we actually, based on the data we had at the time, which was 2015, looked at blueprint practices, which are the only practices we have flags for in vcures, but we didn't find the independence as the lowest paid. For average allowed commercial, we found FQHCs as the lowest paid and for average allowed combined public and private actually FQHCs were very well paid so that kind of, I think it's a better number to look at. But if you're looking at all revenue sources, independence are near the bottom, but community hospitals are actually about 11 bucks less. So, you know, I think we hear, we hear that a lot but our data is not showing it so I think if the data is not showing it we need to figure out a way to get either different or better data from independence so that we can have an apples to apples comparison we have a lot of information around hospitals we have almost no information about the financial situation of independence that is really specific to Vermont. So that's just a comment. And I know you you tried valiantly as part of a rural health services task force to help me with that but it's a complicated topic. But yeah, there's certainly in our view under reimbursement or unfair reimbursement on many codes. So, independence by their very nature independently minded. And this question is probably for both of you. They probably don't all uniformly support this and likewise they probably don't all uniformly oppose it. I'm curious. What what percentage are still going to sign up by the Friday deadline. Do either of you know I do not know that but what I can tell you is in the past years. We estimate that approximately 93% of all of our networks primary care patients were patients at a one care participating practice. So we may not have the majority of our practice in numbers participating but it's our largest practices are largest and medium sized practices that are participating. It's more the solo practitioner old school talk who doesn't want anything to do with the medical industrial complex. So and we're not going to change their mind no matter what.  Vicki are you still seeing people sign up. Yeah that were still. I think you know Kevin there's still the biggest delay is probably in hospitals right now because they're waiting to see on their budgets but I think that will have the majority of hospitals and we've seen probably at this point in time about half of our independence. Come in so we have I think around 35 independent practices. And those true independence or. Yeah true independence. And then our men of home need that half our members of Health First. Most of them are there's two new ones that came in today that I don't know if they're a member of Health First. I think they might be but I can't say for sure. Most of them are from other independence in the south and primary care health partners practices or the majority of them are in the CPR program. Would have been kind of neat today if we could have heard from a provider that decided to continue and a provider that decided not to and really get into their heads. It might have been illuminating. Yeah I think just Susan can probably speak to this getting a doc in front of a committee in the middle of the day in a 24 hour notice is. Yeah. Evenings and early mornings. So I'm still trying to understand the money flow here that obviously there are some independence out there the feel that they might be losers in this relative to where they are now. They are getting three and a quarter per member per month now is kind of a constant payment. And that could go down to a buck seventy five. And that's based on the overall performance of the ACO. You know our targets for health care improvement. So and then others could go up higher than three twenty five. But does that all come out of the same is the pot of money available for this zero sum game that that that winners have to be paid at the expense of losers. No because so one of the things I don't know that this committee is aware of. You know prior to this year the way that we set the ACO was at a community level. So even though let's just use Medicare even though we have a target for Medicare at the ACO level. We used to do it by community specific. Level so we essentially had like 14 mini ACOs underneath the ACO and they all had their own targets. What we found with that model is some of those communities were kind of small and no matter how much you try to adjust for their population health mix. They still become losers because the small numbers are pretty volatile for them. So you might have a situation like we did last year where the ACO overall does well. But you have a community like Bennington who's having to write a check back for a million dollars to the federal government because of the ACO right to the way that it works. So we move to and that would impact the community physicians to write. So the community physicians in Bennington might do well or not do so well. But the community physicians in Chittenden might do well because they were in a bigger bigger service area. So what we've done for this year is it's really a want you know all boats and rise and fall together. Because if you think about it some of these smaller communities absent one care would not have signed up to be an ACO with their 5000 members. They just wouldn't have done it. So this gives each community and each physician within that community a better chance to be able to be successful under this model because we are all kind of working together as a system. And there's not that volatility in the smaller communities. I think that's especially important when we're thinking about COVID. There might be some things that happen within a community that's just not within their control. It's not because they're doing really poorly at population health. They just might have a massive outbreak. And so we need to be cognizant of that and adjust accordingly. Susan you talked about you know 2.5 million isn't a lot of money. I'm still old fashioned. It's still a lot of money to me. And I look at it and you know the people that they lose into one care will be the ones that would be funding it. Even if the docs weren't doing anything that they were being encouraged to do. Do you have have you thought through because what you're saying basically is you know they shouldn't be cut this amount and they shouldn't be dependent upon the whole system as a whole. What are adequate measures on each individual practice that would get the benefits that would be required for the investment of the others that would have to put it up. I mean our primary care practices will absolutely you know work to improve the quality of clinical quality measures relative to primary care their performance. Right now you know they don't know what they're supposed to be improving. No one has told them what needs to be improved what they should be working on. They need that information to be able to improve performance. I mean it's basic quality improvement you need actionable data. So you're saying that you say we would agree with that Susan. And so one of the things that we've been working on this year to say OK if we're going to broaden accountability then you're absolutely right. You have to be able to know whether or not you're winning right or whether or not the CEO is winning. And so we're in the process of creating. And I think it would be I think we might have some health first practices helping us on this. But if not we should talk further about it to say what are those kind of consultative reports at a very high level. How are we doing on cost. How are we doing on utilization. How are we doing on those quality metrics because they're all payer specific. I mean they are dictated to us. I mean it's a negotiation but by the payers they are provided to us. And so that we can give those to the practices and then allow them to go in and see how their particular practice is performing against the rest of the ACO practices who are in a like situation. So that's definitely on the horizon. I think one of the challenges that we've had and you know health care reform is a challenge for everybody. Right. And we've seen the challenges with payers. And I think each year each of them has had something that's happened to them that they haven't been able to give us some reliable data. So that's one big piece of it is being able to get those reliable data from payers be able to interpret them and bring them forward in a meaningful way to the practices and hospitals who are saying they will be clinically and financially accountable for those. So will you bring up a very good point. My concern is OK. We're into September. These accountabilities begin in January. We haven't had the opportunity. Where's the glide path to see reports. You know refine those reports make sure the practices understand the data that goes into those reports. And and you know just see where they stand for a year before being held accountable. It just it's it seems a little premature even though you know our practices traditionally perform very well and we are not scared of performance measures bring it on is what we say. But you know there has to be I think a reasonable path to get from report you know reports to your payments being tied. I would say to that that we have provided overall reports to the practices over the years and that's what these payments have been all along was a glide path to get that way. And we won't know until we get all of the provider signed on who the membership actually will be to see and compare against. So that's something we can't do until we know who the providers are. And once we know who the providers are we know who the patients are. And then we know what our population will look like for next year because we don't have benchmarks though. We know those are still negotiated with payers based on who is attributed to them to the model. So it's a process. You have to know who the providers are. And that's why there's the push from CMS to get these provider lists in so that you know who the patients are and to set the benchmarks. And the ACO doesn't know that until the end of the year as well. It might be helpful Vicki if you could provide the board with a redacted copy of a report that a practice received so we can see what the feedback is and so that we know that they definitely know what they have to work on to do better. I mean that. Yes, I mean I believe what you're saying Vicki but I've heard from my practices that they haven't received anything. Whether it got buried in an email somewhere that's entirely possible. But yeah, I think what we found is that we offer a lot of self service analytics that have this in it. And what we're finding is to your good point Susan is providers don't go in and get the data, right. So we have to find a different way to deliver that information to them. Yes. You know the payers have this figured out they'll you know give reports to our practices and say this we need you to convert six people for a positive colonoscopy and you know they have the names right there and the practices get on the phone and they make it happen. But when it's this obtuse system wide, you know, measure that you have to do better on it just it's not meaningful to the individual practitioner who can actually change that. And we can get an oxymoron Susan a positive colonoscopy. Right. Let's not talk about colonoscopy. Now our gas grow specialist point I'd be happy about that comment. Questions from the board. I just want to go back to the timing of the payments to make sure I understand it so currently my understanding is the 325 comes through on a month to month basis right. So under the new model. How does the, what is the timing of the payment flow for those different components. So under the new model so I just want to make sure we're set the new model is January. So this year's all the same. Right. Yeah. Next year. As soon as we get the data from the payer so we're always we're always a month or so behind. Right. Because we have to find out who the who the patients are. We're going to get that data and there will be the month to month payment and it will be the dollar seventy five for the risk programs and a three. Which is a cut from what they're used to just putting it out there. And then it will be the three twenty five for the shared savings are all called them low risk programs because we have some programs right now that have risk but it's mostly retained at the ACO level. So that will be month to month and then. So let's see twenty twenty one. So in twenty twenty two when the year ends for each of the payer programs that are risk. We'll work with the payers to assess where we are. And if we at least meet our budget. With the payer we'll take that buck fifty and we'll give it we'll write one big check back to each of the primary care. If we exceed the target for that particular payer we'll write a three dollar check up to a three dollar check and first dollar savings go back to primary care. So if there's only enough to cover primary care then the hospitals won't receive a shared savings check. And remember for all of these programs which I don't want to lose sight of is for the Medicare program. The first eight and a half million dollars of shared savings goes out to blueprint and sash. So we're already using most of our shared savings to keep these these programs up and running for both primary care and supports and services at home. Does that answer your question Robin. Yes thank you. Other questions from the board. I guess Susan I just have one more. I'm thinking about this and I want to validate your point that primary care is underfunded. I do think that that's true. I think many people agree with that. But I guess what I'm thinking about here is the decision before an independent practice. Joining or not joining. It's if I don't join. I'm guaranteed to lose a buck seventy five per member per month and the potential to lose four seventy five per member per month. So I guess what I'm just wondering is what are practices that are considering not joining. How are they going to change their delivery system or are they going to have to let go of care meant like what are they going to do differently. Because now they're losing three twenty five that they've had before. But the decision to me seems to be a guaranteed loss of a buck seventy five potentially more than that. So they're going to they are they going to be changing their practice. So they're going to be thinking differently about how they deliver care. How are patients going to be affected in those practices. Obviously yeah. Obviously it'll depend on the practice. But yes I've heard about practices. You know cutting care coordination staff cutting other staff. You know. So yeah they would likely need to make some cuts. Which is unfortunate. And so the patients I mean will patients then move. I mean so to the extent that patients have come to rely on care managers and some of the benefits that have come with these population health. Payments are practices worried that the patients then will lose some of these services and and switch practices. Is that the thought that's entered their calculus here. I can't speak for our practices. We haven't discussed this particular topic. So I'm sure there's concerns. And I'm sure you know they're thinking about mitigating those concerns. Yeah. Okay. Thank you. I just was thinking about that. I mean what we're really talking about is a philosophy. A philosophical difference on you know tying performance to something outside of the provider's control. But also you know essentially not investing in primary care the way we say that we want to invest in primary care and independence in particular they just don't have other revenue streams to look toward. And they rely on the fee for service and the you know one care payments to pay their staff to keep the lights on and it's all they have. So when you know the dollars are taken away they feel it much more acutely than probably other provider types do in the end stuff. Yeah. I hear you. So I haven't been around for the last couple of years on the Medicaid budgets in the legislature. But in my final years here it seemed like we were always trying to allocate more dollars going to primary care. And it's disheartening to see that we don't ever really seem to get real progress if what what's been happening is the commercial payers are continually level level funding. Right. Anything else from the board before I open it up to public comment. I just want to hear Marine talk about the top line and the bottom line in the middle line all those lines in there. On topic. It was like lines I don't see lines. The lines on our faces. Let's not talk about the lines on our faces. Okay. I'm going to open it up to public comment. Yes. Go ahead Dale. Finish what you were going to say. I'm sorry. I didn't mean to interrupt. No. I was just going to say that I was opening it up to public comment. So go ahead. Okay. This brought me back a number of years being on the Sims committees. It was actually like deja vu. I remember sitting in that some room up in the Waterbury complex that had a horrible echo. Trying to ask what MIPS was. And on the hold here we are discussing MIPS. It didn't strike me as being it struck me as being risky at the time in terms of we will penalize you. If you stay with feed for service because there was no alternative. That's five years ago. Or thereabouts. I don't know how many years ago it was. I can remember sitting in another committee and Richard Sileski. If I said the name right. Sileski. Yep. Was making the comment that without a certain number of attributed lives. The ACL model simply doesn't work. I can remember Al saying. Wow. Everybody's on board until they have to take risk. I'm paraphrasing a little bit there. But I'm capturing the general gist of people suddenly had a different attitude when they had to take on risk. And then we were trying to discuss how this model works five years out. And I think that was an online presentation. We're looking nationally at all of the ACL models. And there was only two at that point in time that had made it beyond five years and renewed. And I was trying to figure out why only two. But what I also want to know is how did those two manage to do that. What transpired that made it possible. What was in Colorado. And I just think to remember that I might have even been Colorado Springs. It seems like we're at that conversation now where. How do you extend this model beyond five years. And that inertia that I thought was probably what sinks it. I think we're actually seeing a very detailed look of it. But I give credit to Lori and Susan. You've been innovative. You're doing everything you can to move this forward. I'm alarmed Susan when I hear about care coordination. Maybe being laid off because that is definitely fundamental to everything the ACL is supposed to help accomplish. And it's quality measures. Though the pandemic is doing a nice job of taking out of the picture. Care coordination the way it's supposed to look. This is frustrating. I think it's going to be very frustrating to the consumers as well. Because our costs are going up. And if the quality actually goes down. This is not going to sit well. And if the quality goes down because they can't afford the health care. Then that's just. That's an indemnity that's really hard to describe. And now you've got private providers. They're really saying the same thing. There's nothing in it for me. It's too risky. I can't afford to participate. So this is really challenging. I'm not condemning anybody. I'm just saying wow. I think we're seeing the answer to that question in the very beginning. Why does no ACL seem to really make it beyond five years and a comment. Well let's hope that we might be one of the third or the fourth. Dale. That would be good. Yes. If anybody can do it from Ken. Okay. I have a comment. Yeah. You can in a minute, but Julie Wasserman was the next hand that I saw. Yes, my name is Julie Wasserman. I'm a health policy consultant. Thank you for the opportunity to. Make a few comments. So I'm going to continue this presentation on the ACO, the importance of reduced costs. Making the healthcare system more affordable and ACO savings. I just like to point out that. As far as I can tell none of those have occurred, and I think we should look at reality as opposed to a probability model in terms of reduced costs. and a half percent cap in terms of affordability. I think everyone might agree that health care continues to become increasingly unaffordable and I understand that the state auditor will be producing a report on that in the near future. In terms of savings, if we use 2019 as an example, which is the most recent year for which we have data, my understanding is that Medicaid had a 17 point that the ACO Medicaid program had a 17.4 million dollar loss. I understand there were also losses in the Blue Cross Blue Shield ACO program. So if in fact the PCPs had gotten a $1.75 for 2019, the ACO would not have met its target. In fact it would have overspent. It wouldn't have even met its target and the PCPs, the independents or the group that we're discussing would not have gotten the $3.25. So I don't think we can actually depend on that. The history of the ACO and savings is not as positive as we would all like. So I'd like to inject all of that into this discussion. And then finally, I guess I'd like to point out that it starts to seem like the ACO is focusing on the little guy, the primary care physician. And my question to both the ACO and the Green Mountain Board is when are we going to be looking at specialists and specialty care and maybe putting them at risk? That's where the money is. Thank you. Thank you, Julie. Vicki, I'll give you a chance to respond. Sure, Kevin. I would like to say that we're still exploring with Medicaid. We do not believe it's that level of overrun with them for the Medicare program. The preliminary results are significant savings in that program. And the Blue Cross Blue Shield is considered a low risk. And so for both of those programs, the $3.25 would be reinstated to primary care. Vicki, are you saying that the $17.4 million in losses are really savings? I'm not saying your savings. I'm saying we're still settling with that and looking at the actuarial process for setting those rates because the responsibility within an ACO is to make sure from performance year to performance year that the providers and remember when we talk about the ACO, we're talking about providers, Vermont health care providers that are delivering care to Vermonters. So I'm saying we're still in the process. But even if you net that out, that means all programs one would be achieving as shared savings check which would outweigh the $3.25 currently in play. And in terms of specialists being at risk, the majority of specialists in Vermont are associated with a hospital and the hospitals are all put on a fifth budget as part of this program. Thank you. Hamilton Davis. Can you hear me, Kevin? I can. Thank you. I've got a couple of questions. The first one is to Vicki. Vicki Loner, the charge is being made that somebody's just trying to cut all of this money to primary care. Vicki, can you tell me what the difference is in all of these in your between your 2020 budget and your 2021 budget for the help of primary care? Is there a reduction in the total spending for that category? So overall, I would say we're at about an $18 million budget line for primary care. I'm going into next year, Ham. I'd have to look to see how that compares to 2020. It's also going to take into account like how many lives that we have under the model. Because remember, the more lives, the more investment we're making in primary care. But I would say it's fairly neutral. But you have to look at the $175 versus the $325 versus the $475. So that would be the only change in the overall budget. Going into next year, I think the Green Mount Care Board will see that we've had to considerably reduce all other programs that were not primary care related in order to keep the program moving. In addition to having to reduce fairly heavily costs to be able to run the program itself. So we have done some hard work to preserve all the primary care investments. Okay, but don't you have a number? Do you yet have an actual budget number for your 2021? We're working on that, Ham, right now. It has to go through our boards and committees, but I would say that it's relatively close to current year. Okay, so your budget you think is essentially flat or is it not essentially flat? It sounds like it's essentially flat. Is that wrong? I think it's going to be essentially flat. Flat compared to after maintenance or before? Yeah, my question is, I assume, I had assumed and this may be wrong, but let me ask Vicki this. Are you building your 2021 budget, even if you've got some numbers left to do, are you building your 2021 budget on the new distribution formula for the primary care money? Yes or no? So, yes. Okay, so I think that Kevin, is that what the question you had? No, but that's okay. I'm going to have plenty of chance to ask Vicki questions in the budget process, but it gets a little bit tricky when you talk about flat comparing to this year, because don't forget that they cut this year's budget significantly to get more dollars back in the hands of providers after COVID hit. So, my question is done. Go ahead, Ham. And you get that. My question is this, the charge has been made that what's happening here is that one care is just trying to cut money from primary care for just general purposes because it's hostile to primary care. Anybody that thinks that that's not what's being said is wrong? And so what I'm asking is, is that cut going to show up in the budget? And I think that what Vicki has said is there may be some small stuff that you have to account for differing circumstances this year compared to last year, but that there is no significant cut. That's what I took the answer to be. Yeah, so we're going off from the assumption, Ham, that we'll be able to reinstate the 325. And then any other things wouldn't go into our budget because they'd be part of the shared savings equation. So any shared savings we got would be returned to primary care. And Susan was trying to weigh in as well. Go ahead, Susan. I'm sorry. Go ahead. I was just going to say the cut is to the upfront payments, and that is what is so valuable to the practices. potentially waiting 18 months for potential payment is problematic. My second question is, Kevin, my second question is on the sort of the theme that appears that one care Vermont is not doing enough to attract new members to get programmed. And so I've got a couple of questions for Vicki on that. I'm curious whether you've asked the governor that we want to put the Vermont state employees in on the grounds that fixed price contracts would be safer than none. And whether Vicki has talked to the NEA about whether they want the teachers to be in. That would be a total of at least 50 to 60,000 lives. And that would make a lot of difference in scale. What do you hear from, what do you hear for 2021 from VSEA and NEA? Most of the conversations I've heard is I've been going through the agency of human services as well as Blue Cross Blue Shield, who actually holds the contract with them. It seems relatively positive for the state employees union. I think people are less optimistic about the teachers union coming in for next year, but I don't believe that door has been closed. Just one final one question, if I can, Kevin. Vicki, I understand that you can't, it's perfectly reasonable to say, well, what are the new metrics that might be out there that providers, irrespective of whether they're in or out, if they wanted to be in, would have to meet in order to get the higher number. Can you get the metrics that you need from at least Medicaid? Yeah, so that's part of the negotiations with the payers, Sam. So I think about it as first, the ACO has to negotiate with the payers to get the actual total cost of care targets. The quality metrics are stable underneath the all payer model, which is nice. So it's essentially 13 defined quality metrics that all roll up to the three larger population health goals under the all payer model. So those are always fixed. So the only variable in all of this is really what is the total cost of care target going to be under the risk based programs. But for specific primary care practice, dealing with patients coming in and patients going out, at the present time, the most of the primary care doctors know what those quality metrics are year in and year out. Those are publicly reported in part of the green mountain care board process. And then we have practice specific scorecards, too, if their numbers aren't, you know, if their number gets too small, then it becomes way less meaningful. Okay, I'm going to turn it over to Mort Wasserman. Hi, can you guys hear me? Yes. Hi. First, it's important to point out that Julie Wasserman and Mort Wasserman are not married and are not related, although we have a nice email conversation going on back and forth. I am a retired primary care physician. I'd love to hear from any other primary care physician on this call. But as it was pointed out, they're probably just too busy seeing patients. And although I've never been in practice, myself in private practice, I've helped to train a whole number of pediatric and family medicine practitioners in this state, while at UVM. And nearly all of the research I've done and quality improvement stuff I've done has been with independent primary care practitioners. So I think I have great sympathy for their perspective. And I agree with what Susan said. These are some of the most nimble practices that can turn on a dime that you could find anywhere. I'm really, when I consider something like why aren't more primary care practitioners in one care signing up, I try to fit it into some theoretical framework that I've heard or come to know. And the one I know best is Everett Rogers Diffusion of Innovation framework, because this is an innovation for a practice to go from fee for service to fixed payment to a mix of fixed payment and then to have quality metrics. And I think our practitioners are slowly coming around. But Everett Rogers, from his research, said there were five things, five factors that would influence whether an innovation was successfully adopted and diffused because that's the important part, diffused from one person to a next or one practice to the next. The first and most important was relative advantage, whether the practice was going to be better off taking, innovating, or not innovating. And I think that maybe one care could do a better job of selling the relative advantage than it has been able to do so far. And full disclosure, I worked for one care for a year and a half on pediatric issues. The second factor is the compatibility of the innovation with what they're already doing. And I think one care has done a great job of preparing the ground for this, because in fact, with care coordination becoming an accepted part of primary care rather than an innovation itself, this should not be incompatible anymore with what primary care does. I think our primary care practices are doing successful care coordination around the state. The third is complexity. It's got to be as simple appearing as possible. Here, I think from the presentations we've had, both Elena's presentation and Vicki's, it's not simple, quite frankly. They try to make it simple, but you really have to have lots of examples to show a practice, an independent practice, how much better or worse they're going to do based on data that is already in existence. The fourth one is trialability. Can we just try it out for a little bit? That doesn't seem like you can trial it out for anything shorter than a year, so that doesn't look very doable. And the last one is observability. Observability means one practice can see what other practices are doing. And I see things in Vermont Digger that say articles, oh, we're thinking of dropping out of one care, that's observability, but I don't see the corresponding piece from a practice that's staying in one care as to why they're actually doing it. So I think this is a really exciting time. I think there's tremendous commitment on all parties to the all-payer model. And with the respect to what Ham was talking about, oh no, someone else was talking about Dale was talking about ACOs going out of business. Those are based on historical data. That's not based on what's happening now. That's not based on the CMS of 2020 that's based on an old CMS. So I remain optimistic about this. That's all. Thank you, Mort. Very constructive comments. Are there other public comments? Yeah, Chairman, this is Rick Dooley from Health First, if you don't mind. Sure, Rick. Welcome aboard. Thank you. So, full disclosure, I am the clinical network director for Health First. I'm also a family practice PA at Thomas Chittin Health Center which is one of the CPR sites and we have been a CPR site actually for the last three years through one of the first ones in with Vicki. I do think it's important. I know Susan stated it already. When Vicki says there's going to be 325, the most practices are going to get the 325, some can get extra. That's fantastic. And that's sort of what we're looking for. The problem is really the timing more than anything else. I guess I'm not sure what exactly one care gains by just shifting this money. Because essentially, if you say most practices will get 325, we're just going to pay you in a year and a half. But now go ahead and innovate and try to make some practice changes. The reality is that practices need money in order to survive and certainly in order to innovate. So if we want practices to make changes in 2021 to help improve readmission rates or communication or A1C rates or whatever it is that we identify that one care says here's what needs to be improved. The only way that's going to happen is they have the money to do it. So if they now have to scale back how much money they're spending on their practice and delay that by year and a half, they can't make those changes that need to be made in order to reap all the benefit that they're supposedly going to be reaping here. So I guess that would be my question to Vicki, sort of what she sees as a game how this is going to incentivize. And I know I have done a couple meetings with various folks who want care for things. And there's a lot of talk saying that this is going to incentivize better communication from the hospital. It's going to reduce readmission rates because the hospital will now be incentivized to work more with primary care providers or more with community providers. And I'm not understanding how that's going to happen because they've been incentivized or we've been incentivized certainly to get discharge summaries or whatever for years and we've tried and tried and tried. And I'm not sure how shifting some financial risk essentially will suddenly improve that communication that we've been trying to get for years. So I guess that's the only thing Vicki, I just would like to know how you see this as fostering that innovation that you're looking for. I do think, Rick, I totally hear everything you're saying. I do think that shifting the risk and having financial accountability across the board is the overall model of the ACO. So it's a little bit different than what you've seen in your blueprint models which have been primarily focused on supporting primary care medical home. This is about the system working differently together. And the ultimate outcome is if we can't work better together, there will be no shared savings to be able to even provide that $1.75 to primary care. And so thinking about the long term is how do you assure? How do you make some steps now to have the sustainability of the program so that there's not that cliff that we're falling off from at year five? Because remember next year is the last year of any federal funding for this program. The DSR grants all cease to exist for ACOs. And you know, that's it's three and a half million dollars. It's not nothing. But that's another three and a half million dollars that the system now has to achieve in savings to keep things going. So we really are at a pivotal time to be able to start being able to beat our targets in order to sustain ourselves. So do you think so by cutting the money going to primary care this year, or 2021, because that's suddenly what will happen is everyone gets this sudden reduction? Do you think that's going to empower practices to make the changes they need to maybe get more money in 2022? And it's coming off a year that obviously with COVID.  So if we can't get the money any other way, how do you see that helping us get there for next year? I think that comes back to the larger question we've been discussing is what's the problem the ACO is trying to solve. And there seems to be a historical fundamental problem of primary care feeling underfunded. So remember, I don't have any of the data on that. So I'm not saying it's not true. I just don't have the data points on it. And so the one care or ACO model has to look at the existing fee for service as the basis for everything that we're doing right now. And we need to have those investments coming in the door. And if we don't and we don't need our shared savings, we don't exist. Thank you. Okay, other public comment? I have one more that's more of a question. Go ahead, Dale. It's really meant for Lori. Lori. Sorry. So, Dale, do you mean Vicki? Vicki. Sorry, Vicki Lorner. Who's over here? I'm sorry. It's okay. It's a little puzzling to me. We have an underfunded system. COVID has just decimated our economy. And that concludes the economy of health care. People are really struggling. We don't know where we're at. What was usually reliable isn't reliable. Sustainability is not really known. But somebody mentioned that the quality measures are nonchanging. They're constant. So what that does give me, if that's a constant, I can calculate what my real cost is to get the quality measure with many variables right now because of COVID. I believe it's an underfunded system. So really, we need investment. And this was brought up in the very beginning. Sometimes the best outcome was actually going to cost more money. And if you're trying to create savings, how do you flip that around and show that it's actually a savings? So I'm happy that you're doing what you're doing. You're really great. But there's a paradox there that I'm just not sure.  Do you go to Peter Welch? Do you go to Washington? Do you say, we need money invested? Do you need to go there and say, we need money to support primary care because we're having to cut it. And this is not going to work in the long run. We're cutting the very lifeline of everything we're trying to build. Do you have any input as far as other ideas of what you could do? That's how I know. But if you're on mute. I was going to say, I don't have an immediate answer for you, but I do believe that there can be strength and advocacy if we're all going with a common message together. Okay. That makes sense to me. Okay. Other public comment? So I did want to give Elena an opportunity to ask some questions and actually to lay out a framework for when we will see the list of who's participating and who isn't. But before I turn it over to Elena, I understand, Jess, that you have a question that you wish to ask. Yeah. I just, you know, I'm sitting here listening and I'm trying to process and I'm trying to find a way forward. And I just wanted to throw something out as I'm listening to both health first concerns as well as Vicki, your concerns. It seems to me the ACO is trying to get more accountability for all the reasons that you laid out. It sounds like from the independence, there's two issues. One is a need for better data analytics so that the providers have more information to shape that care and generate the cost savings that will help the overall system. Sounds like you're working towards the data analytics piece, Vicki, so that the providers will have that. Maybe they don't know that, but that sounds like that needs to be communicated to the independence. But the other piece that I'm hearing is the timing issue of the payments. And the concern that the upfront investment is going down, it sounds like from what I heard Susan say, that they're happy, you know, that it looks like the expected payment will still be 325. But the bigger issue is the timing of the payment that they won't get it until the end. So I'm actually just wondering from both of you, if there was a hybrid model here, again, this is like me trying to mediate, which seems to be my calling in life or maybe it's not something I'm good at, but I'm going to throw it out there anyway. Is there a world in which the providers would get, they get the 175 guaranteed, they get the 150 up front, assuming that that's already built in the ACO's budget. But if there isn't savings at the end, or if the ACO doesn't meet the target, those providers will be on the hook for that. And then, but if there's savings, then they would get the additional 150. So in other words, just that middle 150, what is the, has anybody considered giving that to the providers up front, but reconciling at the end based on performance of the ACO? I don't know. That would provide the independent providers with the money they would need to make that care management, all of those primary prevention investments that will actually generate the savings that will help the whole system. You know, if the modeling shows that that's probably that cost savings will continue, then there's a low probability they'd have to pay that back, but they'd have the money up front to be able to make those investments. And then the additional 150, if the ACO generates greater savings than expected, yes, that would come afterwards. So that's not money that they would get up front. So I'm just wondering, that's sort of a hybrid of what's happening now. And I'm just, I wanted to throw that out there to see how either of you would respond. I'm just trying to find a path forward here for everybody. I don't know if that is one, maybe that isn't one, but I'll throw it out there. I think operationally that's something that we could do. I think it would have to be the choice of the individual practitioner or whether or not it's better to just get the 175 and, you know, wait, or if it's better to get the full 325 and then write a check back. And I think even Susan, when we were talking previously about some of the cash infusions, there's a different perspective. And by each practitioner, depending on their individual financial circumstances, but I would say that's absolutely something that's on the table from our perspective. Susan, do you have thoughts on that? Would that be something that would be welcome for some providers? Well, as Vicki stated, I think it will vary depending on the provider. And you know, the other sticking point is the ability to keep that money would ideally rest with the performance of the individual practice or practitioner instead of this, you know, unknown ACO performance. But it's certainly something I could take back to our primary care providers to see what they think. Can I just ask a follow up question? Sure. Go ahead, Robin. I can certainly get by a provider. Susan, to your point, would want it to rest with their individual practice. But my concern there would be the volatility of small numbers because if they're already not choosing to go into the CPR program because they're more comfortable with sort of the fee for service generation, like a little bit of volume change like we saw or a lot of volume change like we saw with COVID could really mess their, you know, their benchmark, if you will, or numbers. So that would be one thing I would be concerned about. It's certainly a valid point. Yeah. You know, we could, you know, look at different ways to approach that. If it's, you know, a road that we'd be willing to go down. I think there are ways to manage that though. Thank you. I'm just curious of your thoughts on that. Yep. So Elena, I'm going to have you try to wrap this up basically by giving us a timeline for when we will actually have the final list of providers that are participating. What are the expectations moving forward as we enter the the ACO budget process and just talk about your thoughts or questions that you might have? Yeah. So I think, you know, we'll have to work with Vicki to get that final list. But I think, you know, at least as we know from our Medicare deadline, the end of September is when that final list is expected. And, you know, I think we probably give them a little bit more time to get that together. The ACO budget is due October 1st. You know, and I think we'll see most of it on that date and then understand that, you know, that they're dealing with this extended deadline for Medicare. So we might see some of that trickling after, but we'll certainly keep you in the loop. And it won't be too far after, right, Vicki? Like maybe a couple of weeks. So we're still working through that. And I think we'll bring that maybe perhaps a request, a request for an extension to those materials to the board shortly. We just weren't prepared to bring that today. But I think, you know, I think the ACO budget process is very challenging this year. I think COVID, you know, a lot of moving pieces, a lot of pressure, you know, an election year, we don't know what's going to happen. There's a lot of things kind of on their horizon to juggle at the same time, hospital sustainability, independent provider sustainability, all of these things. So I think, you know, I can't say what we can expect, but more robust conversation. And I think we just all have to work through this together. I think as it relates to this particular conversation, I think what would be helpful on what we would like to see as staff in the budget process is really a good understanding of the accountability structure that is required of providers and kind of what the theory of change is. Where can they help drive change and how long would we expect that change to take place, right? Because a lot of these models are working on a one-year cycle, but in reality, we might not actually see really substantial shifts in outcomes, in quality and population health for years to come. So how do we quantify, and maybe we need to start measuring on a more detailed basis? You know, maybe it's the process measures that are tied to financial outcomes, and then we gear up over time to the outcome measures, like once we're there, once we're all in. So what is the right transition? And I really love more suggestion of the innovation diffusion framework, because I think that's actually my background is an innovation and strategic management, so I really appreciate that. And it's true, you know, I think we're doing something new here, but we all have to share this vision, and how do we build a shared vision across the state, across the continuum of care, and make sure we're all working towards the same things. It's not just about me getting the biggest check that I can at the end of the day. It's me getting the check when I need it to make the investments, to make sure that remonters are getting the best care that they can, and that we're continuing to build towards these health care reform efforts that, you know, we're all working really hard.  But I think we all still agree that this is the right direction. So, you know, I'm really thankful that everyone was here today, and I'm looking forward to this challenge ahead of us. But you know, I appreciate all the comments and have a lot of notes and things to take back as we kind of start the ECO budget. So thank you. So I was, Chair Mullen, can I just add one more thing or suggest another hybrid option to consider? And that would be what if the 325 was not at risk and the extra $1.25 would be the incentive at the end. So actually what I was going to suggest is if the two of you would agree to have a conversation no later than tomorrow to try to throw some ideas back and forth at each other, whether it's Susan's suggestion or Jess's suggestion, or Vicki may have an even better suggestion. But just to keep the dialogue going, I think everybody learned a lot today. There are some valid points on both sides. And unfortunately, I don't think we're going to resolve this issue before we close this meeting. But I do think that the dialogue has been very healthy. And so what I'm asking you, Vicki and you, Susan, to do is to have a phone call tomorrow just to give it one last chance at coming to some form of resolution. Otherwise, I'm sure the board will be talking about this again through the one care budget process. So I think it's much better if the people that actually have to implement the program thrash this out rather than us as regulators throwing out all kinds of ideas that may or may not stick. Although I will say that Jess, your role as a mediator is incredible. And so don't doubt yourself. You're always trying to find some path forward. And that's greatly appreciated. So perhaps can you, the two of you, agree to a conversation tomorrow? Certainly. Yeah. Yeah. Sorry, I'm on mute again. Yes. Great. So thank you both. And you know, if there are things that we should know that you think of after we get off this meeting, oftentimes we all know what we wish we had said, but we don't have to get it out. Send us an email and we'll go from there. I do want to recognize Representative Lori Houghton who sat through this. And you know, I often as a former legislator feel that legislative solutions are not always the best way to solve these type of problems. And I remain optimistic that the two of you who are such incredibly bright individuals might be able to come to a solution that moves everybody in the right direction. So thank you for taking the time to spend with the Green Mountain Care Board this afternoon. And good luck in your conversation tomorrow. Thank you. Thank you for that opportunity. Thank you for the opportunity, everybody. Nice job, Jessica. Lucy and put your five cents shingle out. You know, it's the result of being a child of divorced parents, I think. So constantly mediating. I'm that too, but I didn't get that skill. Is there any old business to come before the board? Hearing none, is there any new business to come before the board? Hearing none, is there a motion to adjourn? So moved. Second. It's been moved and seconded to adjourn. All those in favor signify by saying aye. Aye. Aye. Any opposed? Thank you, everyone. Have a great rest of the afternoon.