We do this about two times a year. We get out for other reasons, for hospital budgets, et cetera, but we do take the time at least twice a year to visit local communities throughout the state. Our goal is to get all 14 counties soon. We're getting there. But just to give you an idea of what we did that day, when we go out for these traveling board meetings, we ask the community and the accountable communities for help to come together to talk to the board about how they're implementing the all-care model. So we ask them to focus their presentations around the three high-level goals of the model, and for those in the room who do not know them, they are, number one, these are the high-level population health goals of the all-care model. Number one, reduction of deaths due to suicide and overdose. Number two, increasing access to primary care. And number three, decreasing the morbidity and mortality of chronic disease. So in the morning of October 16th, the board went to several sites in the St. Albans area, and they had tours of different health care providers that exemplified and showed the board how this community was. Eight zero to eight to eight to one, seven, seven is now joined. We should just make sure that's going in. Orianna, are you not on the phone? I'll keep going. So we separated into three different groups, and we had tours of the emergency department at the Northwest Medical Center. We toured Northwest partners in health and recovery and Valley Fast Crossroads. And these were examples of how the community is reducing deaths due to suicide and drug overdose. Then we also had visits to Northwest Primary Care, which is on the campus of Northwest Medical Center, as well as Northern Tier for Health, which is the local FQHC. And they also have an office on the campus of the Medical Center. And that exemplified the way that the community is increasing access to primary care. And last but not least, because this was the tour I was on with the board member, Pelham, we went to the St. Alvin's City School, and we saw the way that Rise of Vermont is getting children in the school moving and dancing. And there may be a video of board member, Pelham, and I playing with the answer on this, which I am more pleased with than board member Pelham. I was on the back of a robot, but nobody saw it. And lastly, in the afternoon, oh, and then the last visit was that was exemplifying how the community is decreasing the morbidity and mortality of a chronic disease, starting at a very young age. And then in the afternoon, we had a public board meeting where we heard from Northwest Medical Center, CEO, Jill Berry Bowen, and her team talked about the way they're implementing their health care model, both the challenges and the opportunities. And we came away learning quite a bit from that meeting. I'll just close the thing. We were very grateful to the entire community for that day. And also really impressed with how many community members came out, how many legislators came out, and how many business owners came out to learn more about the health care model and the work before it does. So that was just an update on that really great day in St. Aldens. I want to remind the public also that our schedule for November is on our website. We have a very busy meeting schedule next month. We're going to be hearing from Vital on their quarterly report. We're going to be hearing from our partners at Diva on their HIT plan, and also continue the discussion around this budget process for one care or not. And then last but not least, there is a current public comment period that opened on October 1st when we received the one care budget. This is posted on our website. And I'd ask if anyone would like to share a public comment near our website. You could call our office. You can also send a public comment by mail. The public comment period opened on October 1st, and it runs through November 12th. These dates will allow us, our staff, to incorporate the public comments into the recommendations that they provide to the board on the ACO budget. But I just want folks to know that comments are accepted at any time at the board, 365 days a year. So if you do get comments in after that November 12th of the day, the board will still review that. And that is all I have for you. Thank you, Susan. The next item on the agenda are the minutes Wednesday, October 16th. Is there a motion? So moved. Second. It's been moved and seconded to approve the minutes Wednesday, October 16th regarding the additions, deletions, or corrections. Is there any discussion? Seeing none, all in favor signify by saying aye. Aye. Opposed? Okay, that brings us to the business of the day. It's really good to be talking about the all-bearing model today. And I just wanted to preface the start of this meeting in that despite all the good work being done, most Vermonters don't seem to know even what an all-bearing model is or what we are doing in health care. And so I'm hoping that we can all do a better job of making it explainable. And one of the things I'm gonna ask for today from our staff and from one care staff when they make the presentation is to try to stay away from the PCVs, VHMs, the ACLs, the OCVs. Just speak in clear English so that everyone understands what we're talking about. And I think that, unfortunately, we get so immersed into a very complex structure and help that we sometimes forget that most people are not in that same position and don't have a clue and think we're talking in code when we're trying to explain things. And so we all have to do a better job of just speaking plainly and clearly. And really the assumption is that what we have to make in this communication is that we're talking to someone that really doesn't know anything about the all-bearing model. And I think if we all start to try to frame it from that direction, I think that more homeowners will start to understand this very good work that's being done in health care. So with that, before I call our team up to do an introduction, I did wanna recognize them. This always gets me in trouble. But I did recognize Representative Teresa Wood. And I wanna thank her for coming. Thank you, Teresa. Oh, and Representative Barry Hooper, sir, thank you, Nolan. She's snuck in under the radar. And we really appreciate legislators coming to these meetings. Thank you. So with that, I could invite Elena and Melissa to come up front and to take this off. I'm Sharon Nolan, I'm the board. It's going to be, I'm, I'm, yes, I'm Elena Barry, director of value-based programs and ACO regulation and Mrs. Melissa Miles, deputy director of value-based programs and ACO regulation. So we wanted to start with a little context today before we dive into the main event and provide an overview of the all-bearing model and why we came here in the first place. And then some of the leverage that the board has to release the all-care model and why we're here today to hear one-care budget. So today, you know, we're going to introduce by this context that one-care will present their budget and then with their questions from the board, questions from the healthcare advocate and then public comments. Could you speak up a little bit? Could you speak up a little bit? Could you speak up a little bit? Yeah, yeah. Maybe you could put the microphone a little closer. A little closer, too, yeah. Okay. So I am going to give a background on the all-care model agreement, which, can everybody hear me? Okay. Which was signed three years ago this month by the Agency of Human Services, the Administration, the Green Month Pair Board and the federal government. And each party has a respective role in implementing the agreement. The slide depicts the reason why the agreement was pursued, what the strategy was and is, and the vehicle for doing so, the interventions. So I would like to read a quote from the board's decision to sign the all-care model from that day. The rising cost of healthcare goes to unsustainable financial burdens on Vermonters and their families, imputes equitable access to preventive care and threatens to cripple our state's economy. Left unchecked and un-controlled, it will prevent Vermont from reaching its goal to ensure that all of its citizens have access to affordable, high-quality healthcare. These are the three pillars of what we call our all-care model of agreement logic models. The all-care model is going to be running from 2018 to 2022. We're in year two currently. So these are the levers that will inform the delivery system reform. The model was designed to reinforce and enable transformations in care delivery and primary care. As there is strong evidence that primary care foundation with an enhanced focus on preventive services can improve healthcare quality, improve the health of the population and help to keep costs down. We are testing this through payment changes, including prospective payments and enhanced care coordination models to move providers from episodic care to the provision of preventive care. We're also transforming care delivery and testing what a more predictable revenue stream can do for providers to allow them to initiate additional delivery system reform care in their offices. For example, we've heard from primary care providers that they're hiring additional care coordination staff and mental health support to expand access in their primary care office. It's also creating a stronger network for the continuum of care, including home health designated agencies and the area agencies on aging. So finally, with these two main changes of testing payment changes and transforming healthcare delivery, we are aiming to improve the outcomes that Susan described earlier. And I'm going to speak a little bit more about them on the next slide. So these are the large goals that are in the author model agreement. I will speak to each one individually. So one goal is to limit the cost growth. This requires Vermont to achieve sustainable cost growth for certain services for both Medicare and all payer beneficiaries, which includes most Vermonters. The limit for cost growth in the agreement is 3.5, which was selected as a sustainable growth target because it's tied to economic growth. The state is responsible for ensuring that the programs that the ACO participates in with payers are aligned in certain areas, including attribution, quality measures, financial accountability measures and the different payment mechanisms so that we're moving everyone in the same direction. The all payer model also has responsibility for steadily increasing the scale of the model over the life of the agreement with the bulls on the bottom, 70% of Vermonters in the all payer scale target and 90% of Vermont Medicare beneficiaries. So evidence shows that when programs are aligned, providers have strong consistent incentives to make the changes in their practices. And then finally, the state is responsible for meeting 20 different quality measures, which are bundled under three big population health bulls. And the evidence behind these broad bulls at the time was that 78% of Vermont deaths were due to chronic disease. Vermont's death rates from suicide and drug overdose were in our higher than the nation's average. And the state wanted to instill that underlying value of access to primary care. And the goal for that is 89%. Okay, so these two sides, the Equational Health Care Expenditures in Quality and Access are goals of the state, but the Green Mountain Care Board has a number of levers that can be addressed to kind of affect these outcomes. That is the ACO oversight process, which has two pieces, the budget review and certification, as well as the design of the program and rate setting, hospital budget review, health insurance rate review and certificate of needs. So it's not just this budget process, there are a number of levers that can influence the outcome of this model. As it relates to ACO oversight, when we're here today, there's statute 18, VSA 9382 and Green Mountain Care Board rule five that prescribe exactly how we are to go about these processes and the criteria against which we evaluate one care's budget and any ACO certification. Certification occurs one time following application for certification and then eligibility verifications are done annually to check any differences in year over year in meeting those criteria. So one care has been certified and then we are in the process of evaluating their eligibility criteria under their September 3rd submission of materials. The budget review, the presentation today is an annual review and we are in the midst of that process. So some highlights from the 19 budget order, so that's kind of the, not the final, there's another step in the process but the almost final stage of the review when the board makes recommendations and codifies the budget order. So stale target ACO initiatives, all payer ACO model agreement and data reporting, payer contracts, regulatory alignment, risk reserves, ministry of expense ratio, financial statements, population health management, payment reform programs, the comprehensive payment reform reporting and then value-based distribution methodology, specialist payment pilot and certification monitoring. So these are just examples of areas that can be included in the budget order that might guide one care to achieve some of the state's goals. To just provide further context of where we are in the process for 2020. GMCB published guidance in over the summer and one care submitted their certification and their budget materials. We are where the star reflects today in the budget hearing. To come, we have the staff analysis and recommendations, the GMCB budget vote, as well as the budget order and the final review of attribution, budget and contracts. So we wanna make clear that even once this budget is set forth, there are still a number of variables that we're needing to settle that will really solidify what the budget is that one care will be working with. Any questions or should we just move on? One question. Could you explain a little bit more about why we would take a look in March after we've issued a budget order in December? Absolutely. So the attribution numbers are not yet final in terms of what population that will be serving. So without that, all the work can do is set a contingent path forward. We have some good estimates, but once those numbers are final, the total dollar amounts will be more precise. Thank you. That's always been a frustrating part of this process. I think it's been just spelled out, so everyone. Right. Our hands are tied there. We'd like to see you sooner. Thank you. So we got a couple more representatives come in since we've got all the options. So I just want to welcome our representative, Representative Christensen, to the meeting today. We're always happy to see you after seven, so thank you. Thank you very much. At this point, we're going to invite the one care team down. And while they're walking down, I just want to say that I think that Melissa and I did a really good job of describing what the strategy is. I guess the one thing that I wanted to address with everyone in front of me is that, what was the problem that was trying to be solved? Because Vermont has truly good health care outcomes when it's measured to other states. When you hear the U.S. compare it unfavorably to other countries on quality measures like interpret mortality and things like that, Vermont does much better. And we have a lot to be proud of. But if you take a look back 25 years ago, health care spending was between 11% and 12% of our state's economy. And it grew to over 19% of our state's economy. And so we want to make sure that health care is sustainable so that as all of us grow older, we're able to afford the type of quality that we would expect. That's really what the strategy was laid out in. And when you look at those benchmarks that were put up on the screen by our team, the 3.5% was tied to the previous decade and perhaps growth rate in the Vermont economy. And so what we're really saying is that we're looking for health care to grow at or below the rate of inflation in Vermont so that we can afford it. And that's really the bottom line. So today we start, it started quite a while ago but the submission, we hear a first hand from the one care team about their budget presentation and they get to basically inform everyone what the budget contains. And that's one of the key components of the description of an accountable care organization is that the organization has to be accountable and accountable to all their stakeholders, whether it's providers, patients, and I would say even the general public in Vermont because one care has the heavy weight of being the only accountable care organization in the state of Vermont. And in some respects, that could be something that's very positive because in a small state like ours, could we really afford two sets of administration, two sets of technology and so on. But with that becomes the extra responsibility especially on this board and our role as regulators to make sure that one care is held accountable. So we welcome the one care team today. And with that I'm gonna turn it over to you and I hope that you heard my pre-meeting instructions that we're gonna try to keep this acronym free. We're gonna try to make it easily understandable and please assume that your addressings, whoever in the room has never been to any meeting before about one care or the all care model. So with that I'm gonna turn it over to you. They keep actually, sorry, if we could just begin rest-wearing the witnesses. Yep. Thank you, Mike. Go ahead. Go ahead, your right hands please. Do you swear the testimony you're about to be able to get in truth or hold truth and not be no truth? Yes. Yes. So for the record, Vicky Loner, CEO and care of Vermont, I'm joined here with my colleagues. Hi everyone, I'm Tom Morris, Director of Finance for one care of Vermont. Good afternoon, I'm Sarah Barry, the Chief Operating Officer for one care of Vermont. I hope there's not a buzzer assigned if I do too many acronyms associated with this today. You didn't put out a flying jar either. I'm gonna try my best. So again, thank you very much for the opportunity to be here today, kind of this really important exchange with the committee and those of the public and our stakeholders that are here today. I am fairly new in my role as CEO at one care of Vermont. I'm not new to healthcare. I've been a registered nurse for about 26 years now and I was brought here to this fine state probably 23 years ago by Jim Hester, who has recently passed, but was a wonderful man and also kind of ahead of where we are today that Jim was talking about this probably when I came here 23 years ago. So I'm thankful to him for that. This, as a nurse, it wouldn't normally be the slide that I would put up first, but I thought it was really important because there's been a lot of questions, misinterpretation of what our budget is and is not. And so I tried to break this down with the help of my finance friends to be fairly simplistic. So the first number that you see at the top is the one that's most often quoted. That's the big number that everybody talks about. When you really break that apart, $1.36 billion is money that's already existing and circulating in the system. This is the cost of healthcare as it stands for those payers that we're looking to have contracts with. This isn't new money to the system. This isn't added administrative costs to the system. So when you take that $1.36 billion, what you're left with is the one care budget, which is $62 million. At first, that seems like a big number as well until you really dissect that number and think about what it is. So if you go down a little bit further, it says less network investments for payments. So that's $43 million that's going directly to the healthcare provider. So home health agencies, physicians, nurse practitioners, hospitals, who had said yes to be the vehicle under the all-payer model to help them make important investments into helping Vermonters to be the healthiest people that they can be. That's things like care coordination programs, prevention. We talked about rising amount. Those are all really important investments that we need to be making in order to make this transition to a value-based system. The operating cost is roughly $19 million. And if you even dissect that some more, if you look at it and Tom will get into more details about that, really what that is about 70% of that funding is to directly support providers to do things like understand their data. How many patients haven't been seen in the last year? What are their care gaps? Do they need to get in for preventative visits? Have they hit the emergency room or the inpatient hospital and they really need to be seen? That's the sort of infrastructure and support that the ACO can provide at an economy of scale so that each individual provider doesn't have to pay for those services and supports in our communities. So when you get down to the end, we add zero. So that's also similar to how one care looks at his expenses. Every year we look to break even. So that means even if there are shared savings as part of the ACO, that money is reinvested into the communities and the communities can then afford to continuously reinvest in some of those services that I talked about earlier today around prevention and rise and care coordination. Because when you really look at what's happened since year zero of the model, we'll talk about why it's called year zero. Later, the healthcare providers have made significant investments of their own money into making this system work. I feel like the Green Mountain Care Board staff did a really good job of this but I want to emphasize a few more points. So the all care model, sometimes I have to get a little blurry of like, who is the all care agreement with? So that is indeed between the state of Vermont and the federal government. We as the ACO are the vehicle to effectuate that change.  And the reason why they said yes is because they believe in the goals of the all care model. They believe it's important to have access to care, right? They believe in prevention, suicide prevention. They believe that we really need to do better with preventing chronic disease, both the prevalence and the mortality of chronic diseases. And they understand that healthcare costs are rising and they need to be proven, right? These are all very important goals that are important to the delivery system as well as the state of Vermont. The other thing I want to talk about just a little bit, we've heard a lot that this is an experiment that work has been used a lot. To put it into context, an ACO has done an experiment. An ACO came out of the Affordable Care Act. There are ACOs all around the country that have been operating for a very long time. And they do provide the legal vehicle for which providers can come together and share supports. And that's really important that they be able to share those supports. And more importantly, it provides them the mechanism to be able to leverage some of these benefit enhancements that are provided by the federal government. Things such as being able to go into a skilled nursing facility without spending time at the hospital, right? These are very important waivers, being able to be seen by your home health provider after you leave the hospital, even if you don't have an acute care need. Absente ACOs would not be able to engage in these type of great benefit enhancements. We believe that all of this work is really important, not just to the healthcare delivery system, to the state, but also for the health of our monitors. The system that we have right now is ivory not sustainable and that's the reason why we entered into this agreement with the federal government. Despite some criticism, we believe that we've made some significant headways in our short time that we've been on this journey together and I'd like to talk a little bit about that. Sorry, there's a lot of words and a lot of pictures on this page, but I just couldn't help myself. So, year zero, this was really a foundational year. The reason why it was called year zero, in my mind at least, is because both the state and the federal government recognize that in order to set up this type of system, we really needed to test the model, make some operational changes, do some initial investments, and so that you didn't want to go in with all of Vermont all at once. So, this was really a planning and development year and Medicaid agreed to be our payer partner in that first year, along with four great health service areas that are listed up there, Burlington, Berlin, Middlebury, and St. Albans who still are moving forward in the model as we progress over the years. And then some of our initial payments and programs that we started that were really fundamental was the Care coordination program and understanding that primary care was foundational to this work and so we really needed to bring in some supports and services to help them along this journey. I would say that 2018 and 2019 were great years of expansion. I know that we have a lot of challenges in terms of meeting our scale targets and I believe that there's other levers that we need to be pulling as a state to be able to meet those goals and the ACO recognizes that they have a part in that as well. So, as of 2019, we do have the majority of payers in the program. We've really grown the network in that most health service areas are participating and at least one of the programs, programs meaning Medicaid, Medicare, commercial or self-funded programs. And we really evolved in our investments over the years. You can see starting in 2018 we started to bring in a lot of prevention programs. 2018 was the year that absent big ACO, the Medicare blueprint payments, the SASH payments would have gone away and those would have been at least upwards of $7.5 to $8 million that would have been lost from the state absent the ACO. 2020 is really a significant growth year for us if things go as planned. So again, this is a matter of timing when we look at what our numbers are and what our contracts are. But we're looking to have at least 50% up to approximately 50% growth in both attribution and total cost of care and accountability, adding in new payer programs through MVP, looking to partner more tightly with Blue Cross to shield around a self-funded offering and adding on the majority of health service areas so we cover essentially the whole state. Our payments and investments to providers continue to grow through the years. Those are things that we're gonna have to have discussions about because as we noted one of the challenges for the hospitals that are supporting these investments is the balance between the amount of risk and risk exposure, the amount that they're able to invest in the model if we are really to get to scale. Talk a little bit about the value of one care. And again, when I say one care, I'd like to put a face on that of the 2,400 providers who are participating and using the ACO as a vehicle for reform. It's not just the 70-some-odd people of in Colchester that are working on this. This takes a provider community, it takes a village in order to do this type of reform. This is really about how the system is coming together to deliver better healthcare for Vermonters at a price that is sustainable for that and grows at the rate inflationary rate. As I said earlier, one of the programs that we first launched was a care coordination program. And really what this is aimed at doing is helping to support some of our most vulnerable Vermonters to make sure that they get the health and mental health needs met and that their goals are met so that they can be the healthiest people they need to be. We've actually been recognized by the Robert Wood Johnson Foundation around our model in that it is extremely inclusive and uses a team-based approach, meaning that your caregivers, your primary care, somebody from your primary care offices, your home health, your designated mental health agency is the person that's working together with the patient to make sure that their goals are developed collaboratively and met. We have seen a six-fold increase since we started in the amount and the number of people who are being served through these care coordination programs. And when I say being served through these care coordination programs, I don't mean that they picked up a call from somebody in the doctor's office and said, yes, I'll be involved in care coordination. People that are working with our care coordinators in the system, right, with their primary and care physicians have actually agreed to participate. They've set their own goals and they set and plan a plan and motion to be able to meet their goals. So it's the deepest level of engagement that you can think about. So that number is fairly significant considering it takes upwards of one to three months to do that far along in the process. And speaking as a former face manager as well, I know that it's not always easy to form those relationships and move things forward in order to meet people where they're at. We had, as we're looking at things, and I don't want to steal all Sarah's thunder here, but I'm just going to steal a little bit. We've seen a significant reduction in emergency reviews for both the Medicare and Medicaid populations up to 33% in Medicare and 13% in Medicaid patients. And through a project that the BNA launched, they were able to show that they had upwards of $1,100 per member, per month. Sorry, no, there's an acronym. Savings associated with providing this level of care coordination. I think the second piece that's really important that we talked about that's foundational to our work is making sure that primary care offices have the services and supports that they need. We launched a comprehensive payment reform pilot, and that's another terrible acronym that we'll have to work on in order to make sure that primary care we're able to have the access and supports in their offices, regardless of who the payer was. And this process and this program has been very successful and grown significantly since we first launched it. I think I have a slide in here later. Dr. Joe Haddock, who is really talking about some of the good effects of that program. And when I even look at our budget this year and our review dissected a little bit, it's about $22 million going out to primary care because of the ACO being in place. We've also, as I said earlier, sustained the Patient Center Medical Home Community Health Team and SAFSE funding through the footprint. And this is very important money that communities and primary care offices would not have if the ACO wasn't in existence. A big piece of our budget is really around data and how data informs care. And this is really important when you're asking clinicians to take accountability both financially and clinically for some of these tough but good outcomes that we're looking at under the model and that it can provide them with some real time data to understand which patients haven't come into the office in the last year who hasn't received one of their preventative health visits. It also lets them know, like I said earlier, if somebody's in the hospital or immediately in meeting some supports wrapped around them. We have seen one of the big measurements and Sarah's gonna talk more about this later is a significant increase in the number of high and very high risk. I sometimes refer to them as normal patients that have had a visit with a primary care physician, nurse practitioner or a physician. So smarter care, this is where I'm getting my spectacles a little bit so I'll just turn to my actual piece of paper here. It's really what we're seeing is this system has enabled us to make more investments in primary care programs such as Ry Zermatt and the Dulce program that was launched last year for kids who are at risk for adverse childhood events. And because of these investments, we have also seen a reduction in some of those high cost care such as emergency home use. I also like to think about this as a better care experience for individuals and patients who are receiving their services and when I say that I'm referring to things like the skilled nursing waiver. So this enables somebody to go directly from their home and feed it into a skilled nursing facility without having to first go to the hospital or go to the emergency room to receive their services. This is good for the system because it lowers costs and it's a better experience for the patient. One of the really important things that we partnered with Medicaid right off, although it was a little bumpier than we thought it would be was really stopping the prior authorization process for those individuals that were part of the ACO. So instead of practice having to call the insurance company to get approval prior to, which is costly for the insurance company to have those resources, it's costly for the healthcare provider to have somebody in their office to make those calls and it takes away from time with their patients and potentially delays people from receiving the care that they need. So this was a huge benefit of the Medicaid program. We're working with our other payers to assess what the timeline would be to doing something similar now that we have a few years of data behind us to show that the overall cost doesn't go up when you remove these requirements. And then the reason why this is all made possible to us here today is because we were able to really live under a fixed budget. So what has happened with the Medicare and the Medicaid program is they've been able to set a budget for the programs that providers are participating in. And this is really important so people understand where investments can be made and how much funding that they have for the year. This system really incentivizes versus penalizes for quality. So it incentivizes providers to really make those upfront investments in quality. We are one, I think the only stage who is living under a fixed perspective budget for all or most of the insurance periods that we work with. Right, so if you're still questioning the value of the ACO and what it means to providers, I leave you with this testimonial from Dr. Joe Haddock who's an independent physician at Thomas Chittman Health Center. And the key thing that I'd like to take away from his statement here is that the care coordinators have reduced the fragmentation of the healthcare system and it was resulted in through a hospitalization. So that's what we're talking about here, really creating systems, breaking down those silos and reducing the fragmentation. But that, I believe I am going to turn it over to my colleague, Tom Lores. I'm just going to talk about the current results. So we start with a little bit of an overview of our 2018 results and in doing so, I'd like to also try and explain the way in which these programs actually work. They're quite complicated, but I think we can achieve both outcomes here. So slide on the screen, I'm going to start with Medicare on the left section. The bar you see on the very left is our contracted total cost of care. This is the result of the agreement that we providers make with Medicare with payer and we agree that we will take care of the attributed population for $339 million. At the conclusion of the plan here, we add up all the claims, all the costs that were incurred and it turned out to be $322 million. What happens then is that there is a settlement process that essentially reconciles between the initial agreed upon price and what the actual total cost of care experienced, what, what the providers were paid. And in 2018's performance here, this resulted in $13.3 million payment to the provider network. Next, Medicaid in the middle works generally the same way with one nuance I'll explain in a moment. $117 million agreed upon price to take care of the attributed population. The providers were paid $118.6 million so that resulted in a $1.5 million payment from the providers to the payer to reconcile that program. The one nuance with them that's really important to consider and factor into analysis of the results is the fixed payment model. In the Medicaid program, the fixed payment is an unreconciled payment. And to try and explain this one, think of it like a salary. If you're set and you make a set salary over the course of the year, you try to live within that so that your mortgage payment, your car payment, groceries, et cetera are all within those means. In 2018's business, the providers were able to live within those means and benefited to the tune of $7.6 million. So when you net out the payment that we did have to make to Medicaid in the year with the performance under the fixed payment model, it was a positive outcome of $6.1 million. Blue Cross Blue Shield of Vermont for the qualified health plan program, we agree to take care of the population for $120 million. The actual cost of care was $122 million. So we've owed that money back to Blue Cross to reconcile the program. That's the providers taking accountability for the cost and quality of the work that they deliver. So it's really important to understand 2018 was a really strong start and we have a net of all these programs are really favorable outcome. 100% of these funds were reinvested in the provider network. Nothing stays at one care per month. And those funds go to reinvest in the population health management programs and Sarah will speak to a little bit later and also sustain the funding for the blueprint program which we're able to keep alive in the state by entering into the all-air model agreement. The last note on this particular slide is we shouldn't expect this really favorable outcome every year. We're trying to live within a stable growth rate over time. Some years we're gonna net, receive positive reconciliation money back to the providers and other years we're gonna owe money but that's actually these programs mechanically working the way they should. They're building instability when we do these year-on-reconciliation processes to maintain hopefully that flat and sustainable growth rate that we're all looking for under the all-air model. So to continue the story around 2018, I wanna take a moment and reflect upon our quality performance as a network. And you can see by looking at the summary across the top that we had a very strong performance across all of our pair programs ranging from 85 to 100% achieved in those programs. But it's not enough to look solely at that summary information instead we need to dig a little deeper and understand the context in which this information is being collected. And I think one of the important points for us all to recognize is that as the all-air model advances through the years of the program, there are models in place that advance the underlying assumptions around how the ACO will actually earn those quality scores making it more and more difficult each year as we enter into and then progress through the program. In the early years, which is really what we're reflecting on as we look back at quality scores in 2018, we have to recognize a couple of important points around context. First of all, Vicki spent some time showing us what the network looked like in 2018 with just a few communities and then how it's progressed in this year and we anticipated progressing in 2020. So when we have just a few communities participating, we have to pay attention to nuanced details, things like how many patients actually had specific conditions that we were trying to measure in those communities. What was it about the actual measures themselves that either state consistent and allow us to do some comparison or in fact changes occur, such as definitions around how data are being collected. And those types of changes are not driven here locally. They're driven through national performance benchmarks so that we're able to then assess our performance in each of those programs, be that for a population insured by Medicare or Medicaid, for example, against other national standards. The other nuance that we're often asked about and I think is important to understand is that while one care is actively using data and providing it very frequently to all of our providers in our network to help inform the changes that they are trying to make, we don't have access to all of that information. We are not allowed to receive information for individuals who choose to opt out for sharing their data with one care, nor are we able to see information related to substance use disorder claims in the system. And so that does make some of the comparisons that we are asked to perform challenging when we don't have the entire data set. So some of that information comes from our care partners. We are, however, able to look at some of the particular quality measure performance for chronic conditions where our staff are actually going out and collecting that information from electronic health records and charts from across the state. And when we do that and we look at those four communities that participated in 2018 in the program, and then we look to see what's happened in their performance, I'm very happy to share with you that two of those four communities have improved the rate of care for patients with diabetes. Three of those four communities have improved the care of individuals with hypertension or high blood pressure. And again, two have improved their ability to screen for depression and have the appropriate follow-up steps in place for individuals who are identified as potentially experiencing depression. The final measure that we collect that way is around tobacco cessation counseling. And we're not able yet to provide comparisons because that was a new measure for us in 2018. So looking at some of the areas of strength across our provider network and what are some of the opportunities where we may need to focus more attention as a provider community, we see on the left, for example, that when patients are asked directly, they are reporting that they feel that their providers communicate effectively with them, they have the access to primary care that they need and are looking for, and that their care is well coordinated. They also know, for example, in the Medicare population that providers are doing an excellent job of caring for individuals with diabetes and helping them to maintain good control of their blood sugar levels and help them live healthier, happier lives with a condition. In terms of areas of opportunity, at the same time, we do see that there is opportunity in some of our other peer programs to focus more specifically on helping individuals that do have hypertension or diabetes. We identify a need to continue to work with our hospitals and our community providers of all types to help individuals not end up being re-admitted to the hospital. And we also are focused in particular on addressing new and creative strategies to try to bring adolescents into their primary care provider's office more often because we know that that is a great opportunity to promote health and wellness opportunities, to screen for potential areas of both strength and opportunity, as well as to set good health promotion messages that will carry them throughout their lives. I do note that while we consider that an area of opportunity, when you look at the national landscape, one care is currently performing 11% above the national average for Medicaid and 19% above that median for the commercial qualified health plan exchange program. So just a few highlights to show you some of the work that our providers are performing day in and day out on behalf of patients. And we're going to spend some time now talking about the budget, but I will be back with you in a little while to share some success stories and some of the results that we're seeing from all of this great work. Before you start, John, I just want to confirm. Maury, can you hear everybody okay? Yes, we're here. Great. Thank you. All right. So let's break this budget component of the presentation into two different parts. First is going to be about ACO program budgets. This is really that total cost of care attribution and risk-based. The second part will be more focused on the actual one care organization and its budget. So I'm going to start really building off of the first slide that Vicki shared with us today and look at Vermont's healthcare accountability in a little bit of a different way. The high on the left represents the healthcare costs for Vermonters. So this is our Vermont residents and the costs for them to receive healthcare regardless of where it's delivered, whether it's locally or in a different state. That's about $6 billion on the annual basis. The yellow section of the pie is one care Vermont's accountability per the budget submitted this year. That's about 23% of the overall healthcare costs for Vermonters. So we're growing in that space but still compared to a small slice. Again, the yellow slice is not new costs, it's not new funding. This represents the portion for which the providers are financially accountable. As Vicki mentioned before, this is about a 50% increase over the prior year. So another large in total cost of care accountability. Underneath that total cost of care accountability, we can do some innovative things. And one of those things is the fixed payment model. So when the providers are financially accountable for the cost of care, we can work with the payers to change the way that they pay for healthcare. And the fixed payment model is one that we've been operating for a couple of years now and anticipate again in 2020. 35% of the anticipated healthcare costs under one care's accountability in 2020 will be in that fixed payment model, which is great. We anticipate and hope to grow this into the future. It'll never be 100% fixed payments for basically logistical reasons. If somebody receives services out of state, it makes more sense for the payer to continue to pay those claims directly. Another interesting point in doing some research is that Vermont's one of eight states with more than 20% of the residents can evaluate care programs. So we're a growing cohort in this country of states that are really putting a lot of effort behind the accountable care model. So all the work that you're gonna hear about downstream of this program is dependent on these program contracts that one care enters into with the payers. And in 2020's budget, we have a continuation of a number of programs and then a couple of new program offerings that I'll share with you today. First, starting with the existing programs, Medicare will look relatively true to form and consistent with the current year operations. The one number that in the financial space I'm always looking at is the trend rate. And that is modeled in our budget as 3.9% at a source from the Medicare's national United States per capita cost forecast, which is a term that's referenced in the Vermont All-Payer Model Contract. So that was the basis for that increase. Medicaid, the big story here is geographic attribution. I'm gonna stop us to speak about this for a moment. Attribution is generally driven by an active primary care relationship. But what happens to someone who doesn't have an active primary care relationship? They're largely unattributed and miss in this value-based care world. So we've been working with Medicaid to understand the population that do not attribute to one care, what are their characteristics? What are some sub-pools and categories within those lives that are missed and how might we responsibly incorporate them into our programs? And this is a really exciting, we're learning a lot in this space about why somebody might actively be receiving healthcare but not through a primary care provider. And the budget does not actually include model attribution growth because of this timing and availability of data. But we are really excited by this opportunity and hopeful that it will be something that we share in March when we come back for our final attribution numbers and show you the results of that. Blue Cross Blue Shield of Vermont with the Qualified Health Plan Program. The story here is that we are anticipating the pilot of a fixed payment model, likely to begin in Q2 with a select number of providers easing into that model that would really like to develop a fixed payment concept with that payer as well. The University of Vermont Medical Center Self-Funded Plan, this is a one care UBM Medical Center ACO arrangement we had in 2018 and 2019 for their health plan. We actually aimed to sunset that program and roll it into a program that's now on the right hand column. This is a Blue Cross Blue Shield of Vermont Self-Funded Program that is new and something that we in collaboration with Blue Cross have been developing in the last few months to bring in a significant number of their self-funded business. So this is multiple employer groups for whom Blue Cross Blue Shield of Vermont is the plan administrator and develop a program with Blue Cross and one care to roll these lives into a scale target qualifying program. This is really what is in the next level slide significant enhancement into this commercial space. And last and certainly not least is a new program in development with MVP to bring their qualified health plan lives into a scale target qualifying program in 2020 anticipated to be upside only for year one. And just like our other Q and P program linking the benchmark to the Green Mountain Care Board approved rate filing. So we have that connectedness between rate filing and the ACO program. And in our discussions really have been focusing a lot on the clinical initiatives and how we can collaborate to build the strengths of both organizations and have an integrated and coordinated clinical model. All right, we'll go on to the next slide. 47% attribution growth. And what you'll see the way I'll just display this slide here is the grant was the existing 2019 attribution and then the color component on the top is the year to year change. You'll note the big change is really in that commercial self-funded category that's reflective of this new program anticipated in partnership with Blue Cross and the Shield of Vermont. In the commercial Q and P space the growth is really driven by the MVP program and bringing that on board. And in Medicaid while there is growth here it's largely driven by new provider community coming in as well as a couple of new providers joining for the first time as well. If we're able to succeed in our geographic attribution endeavor that has the potential to add even more lives into the Medicaid program. So it's really important to note here that attribution is one of the core and key components that drive everything that comes downstream. So when we grow our attribution which is what the Vermont All-Pair Model calls for that results in the growth and the total cost of care that ultimately shows up as that big number on the top of the page and beginning of our presentation. So it's just important to understand the connectedness to get the lives and the total cost of care which we're accountable is going to increase with it. When we think about the future and growth opportunities and attribution I think it's really gonna be the magnitude of risk which I'll talk about in a few minutes as well as the attribution methodology that will really help us yield continued growth in the next few years. If we're successful in the Medicaid geographic attribution model transitioning that into the other payer programs will be the next logical step and really sustaining the growth that we've experienced over the last few years already. All right and from the attribution growth comes total cost of care growth. A similar theme we'll see the commercial self-funded growth as being the most significant portion that's related directly to the lives coming into the model and then more modest growth in the commercial QEP and Medicaid that just reflects attribution growth accordingly there. One of the other interesting notes at least to me that we'll see up the next slide really is on the prior slide the Medicare bar, the attribution bar was the second smallest but on this slide here when we look at total cost of care it's by far the largest, nearly double next the next largest program. That's where the risk discussion often goes when we talk about risk it's often around the Medicare program and this is exactly why the spend for the Medicare program on a per person basis is significantly higher and that's basically a result of the aging population and their healthcare needs. All right and then next we have total risk. So this is the number that results when we take our total cost of care estimates and we apply our risk sharing terms and come up with what I think of as the worst case scenario. So the worst year we could possibly have and it's a big number up to 44.1 million dollars. In 2020's model hospitals remained the primary risk bearing entity and the magnitude of risk particularly in the Medicare program is a barrier to continue growth. That was something we experienced in our 2020 network development process was that risk particularly in Medicare was substantial. Reserving for that risk remains essential and my opinion and really is an important aspect for the sustainability of these programs. Really what I'd like to see is that any one of our participants risk bearing entity participants can make a downside risk payment if it's owed and also sign up the next year. That's what we're trying to achieve is the sustainability of this model and approach. It's really also important to note that these hospitals which are bearing the risk on half of our network they're on the hook for four to $10 of risk and they're not even providing that care. That could be somebody down the street providing that care could even be out of state. Two out of every $10 of risk is completely out of the one care network. So they're bearing risk on behalf of the network and reserving for that risk is a really important factor to consider. All right, so that was the overview of our ACO program budgets. This is really the one care for my budgets and I'm thinking about the budget that we maintain for the operation at Colchester. This is it. I'm gonna start with an overview of the process and really how we build this budget. And then the slides will follow suit in a similar order. But I think that this perspective is helpful to understand. The first thing that we do is really evaluating our population health management programs. What are the clinical initiatives that we would like to focus on in the upcoming year? What are the gaps that we may have not focused on the prior year but it's appropriate to get into that space now? And what are the associated costs of those programs? Next, we take a look at the operating budget. This is really the one care for my called the floor but it's the team at one care. And what are the FDs, the positions and other clinical tools that we may need to support those population health management programs as well as facilitating all of these contracts of the payers. Those two combined really result in our expense budget. That's what it costs to run one care for much. Next, we look at and forecast payer and state investment revenue. What other revenues might we be bringing into the ACO to help us on this journey and help pay for the expense. And then last, we evaluate unfunded expenses and that's really the hospital do. So as Becky mentioned before, we operate this as a break even model. So we're calculating those dues just to get a break even point. If when we get to step four, those dues are unpalatable to the participants in the network, we go back the loop. What might we be putting in that first section of population health management programs for an operations that we could do without and might we cut some things to ultimately result in dues that possible partners can afford. It's also important to note this really is an ongoing process as we do it for the cycle. But as the team mentioned early on, once we get our final attribution numbers, we'll go back and redo it because the attribution will affect many of the costs in the population health management budget. So it's an ongoing iterative process. All right, so in the same order, I'm gonna start with the population health management investment areas. So we offer a number of programs and Sarah will speak to these in more depth, but we decided to craft this slide to break them down into a number of investment areas and really speak to what the purpose of each of these investment areas is. And again, the contracts with the payers upstream are really what's critical to unlock the ability and the incentives to do all of this work. So starting at the top, we have care coordination investments. This is just over $10 million. Use our payments to fund our care coordination model that aims to encourage cross provider collaboration around our highest risk patients. Primary care, another $10.5 million investment, really intended by the resources to move us towards a population health focus and also paying attention to the all care model goals. Next, we have quality, $8.5 million. This is a significant investment here in incentivizing focus on the quality measures that we believe will help us do well under the all care model. Primary prevention, just over $1 million going to the network. These are investments in wellness initiatives that are designed to help keep the wealth population healthy and prevent them from becoming higher risk patients. Specialty care, so development of specialized program models to enhance access and coordination of specialty care that includes mental health, also exploring the pharmacist space. And then lastly, we have blueprint programs. So this is sustaining the funding for the sports and services at home, SASH program, community health teams and patients that are medical home payments. Again, these payments would have ended coming into the state of Vermont if it were not for the all care model and one care's contract with Medicare. I'll note at the end, all of these figures in total tally up to $43 million. This is a significant investment in these programs. This does represent funding opportunity. We are shifting many of our program payment models to pay for active engagement in care management rather than capacity building. So what our actual cost will be is going to be dependent on provider engagement as well as the attribution that we experience as we move it into performance. All right, this is a different perspective on the same numbers. You'll note that the total at the bottom of the page is the same, but the categories along each row are different. And this is intended to show who is receiving the investments that I spoke of previously. So we're starting at the top. Again, we have our primary care providers, $22.7 million going into primary care. The box to it's right, you'll note is quite filled as the primary care is the centerpiece of many of our programs. They received the one care from PMPM, the member for one payment, their participants in our care coordination program and value based incentive fund opportunity, participants in the conference of payment reform program, innovation fund and blueprint programs. Specialty in acute care, just over $5 million. The specialist program that we operate contributes funding as well as the diabetes incentive fund, XLC SASH, that's one of the blueprint programs that we sustain the funding for. We have designated agencies and mental health providers that's $3.4 million, their participants in the care coordination program, diabetes incentive fund specialist program as well as the innovation fund. Community health teams is another blueprint program. Community investments, these are largely the rise or not primary prevention related investments in community entities that are not necessarily health care providers but can provide health benefit to our citizens. Home health providers, care coordination program participants as well as the value based incentive fund opportunity. There's a 2B determined category that's largely related to the innovation fund where there will be a proposal process in 2020 to solicit ideas in the one care and we will select the ones that we believe have the most significant impact and can be scaled across the network. And then lastly, we have the area agencies in aging and these organizations participate in our care coordination program as well. Okay, so we just covered our population health management expenses through two different perspectives. Now we're onto the operating expenses in one care of Vermont. So just like any other organization each year we evaluate anticipated demands on the organization and make adjustments as needed. And some of the FTE areas, the employment, employee areas that we've targeted in the 2020 budget include analytics, finance and legal functions all of which we recognize as areas needing additional resources. We also just like any other business evaluate our overall expense management, what kind of contracts we have, are we being good stewards of our financial resources and make adjustments accordingly. One of the other views that I like to share is we look at our one care for Vermont expenses through some different functional groupings. And you'll see on the bottom the bar chart breaks down our operating expenses into a number of different categories. The six on the left are really categories that provide support for our network. Just about all of these could be directly hired by network participants. They could hire analysts, they could hire clinical consultant type people but it's more efficient for us to do essentially the ACL and supply those supports to them. In total, these network supports is over 13 million and it's just I have 70% of the one care operating expenses. The next category I've called out here is regulation expenses. This includes agreement and care board build back and time and energy that goes into the regulatory process. And then the last one on the right is, I think of this general administration that just about any business has to stay alive in an operation. And that's about 24% of our budget. All right, this next slide really shows the economies of scale we're starting to realize through this model. And you mentioned this at the top of the presentation. What we're seeing over time is that as we grow attribution and grow our total cost of care, our operating expenses as a percentage of that total cost of care is continuing to decline. I think this is a really important metric for us to pay attention to and make sure that we're maximizing this economy of scale concept. And at the end of the day, the one care operating costs, and that's the total, is only 1.4% of the total cost of care. I mentioned this in the budget narrative but it's hard to find really benchmarking data for other HCOs, but in the few data points I've seen, this is quite long. Okay, so when we combine these two expense groupings, the population health management investment expenses with the operating expenses, this is the result. The top section on the left are all of those population health investment areas that we spoke of before, totaling $43.1 million. Next we have our operating expenses in those three buckets and network support regulation general administration. And in total, we have our $62 million budget that you mentioned at the beginning of the presentation. When you break that down into the pie chart on the right, you'll see just shy of the 70% of the direct payments going right to the provider community. 21% of the budget is network support for those providers. 3% goes towards regulation and 7% goes towards general administration. Just note the percentages on the slide reflect the proportion of the 62 million, whereas the previous slide was just a percentage of the 19 million operating budget. Okay, one of the areas in our budget that has generated some attention is the state investment category. I'm going to attempt to shed some light on this and explain it, but let's note it's pretty complicated territory and there is some nuance in here that's important to understand. So in our income statement on the submit budget, there's a state investment slide. That's where the bulk of this revenue shows up, but underneath there are some caveats that are really important to understand. The top section of this grid represents delivery system reform investments, commonly referred to as DSR funds. These were funds that were made available to the state of Vermont to help us on this journey, delivery system reform, to transition our healthcare delivery system to a value-based paradigm. In 2019, we received just shy of $3 million in delivery system reform funding. In 2020's budget, 7.8 million is included, which is an increase of just over $4.8 million. Next, we have other state investments. The state helps us fund our health information technology platform. This is the data warehouse and analytic tools that really support all of the work we do. We cannot do this work without those tools. In 2019's budget, there was 2.75 million, and in 2020, the budget, 3.5 million, so about $750,000 increase here over here. This next piece is certainly nuanced, but it's important to understand. This is the one care fixed payment care coordination allocation. When we sit down with Medicaid, Diva, to set our Medicaid total cost of care accountability, actuaries come up with the total, here's what it should cost to take care of these lives. We then have the option, as one of the payment reform opportunities under value-based care, to convert some of that funding into a fixed payment or a payment to cover care coordination. So, in one care's budget, going from 5.1 million up to 5.3 million in 2020, we are converting $5.3 million of, what I'll call old claims funding, into a fixed payment concept to help us plan the care coordination program. Another way to think about this is that there's no care coordination building code that can be built. So, we are essentially creating that within our one care program, where we pay for care coordination and just trade it for what would otherwise be claims in a fee-for-service system. That actually comes at no cost to the state that's already baked into our healthcare costs and already incorporated into the actuarial science that determines how much it should cost to take care of the attribute population. When you total all of these up, it results in the two rows that you will find on our one care income statement. Healthcare reform investments, $13.1 million, and health information technology, $3.5 million. This does represent an increase over the prior year, all told, of 5.75 million. The other factor to consider when evaluating these funds is the state match. That essentially means that the state of Vermont pays a share and the federal government will pay a share. The match rate can be varied and complex in nature, but we've done our best to estimate the state's contribution to each of these different funding initiatives. For the DSR funding, $3.9 million of state dollars to unlock the $7.8 million in DSR, $630,000 for the health information technology, so it costs the state of Vermont $4.53 million to bring in a full 16.6 that we will use to help us honor care transformation journey. When you look at the year over year increase, it's not shown on this slide in terms of the state's investment, basically take the year-to-year increase and apply the state match rates. We're asking for additional $2.75 million of funding for the state of Vermont in the 2020 budget. All right, this is the full one care budget summary. So this combines in the top section our incomes with the expenses and you get to the bottom. So starting at the top, I didn't go into tremendous detail on the payer program investments. Generally they're PNPM investments that payers making the one care similar to what you've seen in the past. It's $10.7 million. We've itemized the delivery system for $4 for new programs, $6 million, as well as the delivery system dollars for existing programs, $1.8 million. So some of the new DSR, some of the DSR funding that we're asking for is actually existing programs that we just would like to continue in the future. We have our $5.3 million in the one care fixed family care coordination allocation. We have $3.5 million in healthcare information technology investments, a few other investments. And then the last two are related to hospitals. The first one is hospital contributions to blueprint. That funding in the first year of the El Pair model came through in the Medicare target. Those dollars are effectively at risk if we were to have an overrun in our spending. It essentially means the hospitals will have to come to fund these. So it's contingent upon performance, but I did want to identify those as really hospital contributions of blueprint according. The last is the hospital investments line of $24.4 million in total UCR total budget of $62 million. A couple other notes here. Again, break even budget. So we're anticipating that revenue equals expense or one care for one. We're also not building any reserves in the 2020 budget model. The way in which we would do that is to run an operating gain. We're not an insurance company and we cannot book expenses to reserves. Or at least have not found a way with our honors to do so. So we are running this as a balanced budget and maintaining the reserve amount that we anticipate having at the conclusion of 2019's performance here. What we need to do and would like to do in partnership here is evaluate our actual 2019 performance and firm that the ending reserves are adequate for our needs. And then if needed come back with any requested adjustments. Continued investment in the provider network. You saw all the population of management investments of $43.1 million. We think this is really important to have forward to sustain the momentum that we've already begun to generate. And then the last point is all care model continues to rely heavily on these hospital investments. Really we would not be here without their contributions. And through 2020, if this budget model goes through as proposed here, it will total $74 million of hospital investment through over the duration of that all pair model era. And that is one of the topics that we're gonna have to look into in the future. How is not to leave on a challenge. We still have a lot of really good information to share with you about the success of our model and Sarah Berry is going to go into more details of that. But I thought it was really important that we step back and recognize that operating this level of reform is hard work. And it's really easy to sit on the sidelines and criticize the work in the progress to date. And it's another thing to really roll up your sleeves and be part of the solution. And we believe what the state of Vermont is doing with the federal government as well as the providers in our network and the legislators that sit here in the room today and our stakeholders in the administration are really rolling up their sleeves to be part of the solution. It isn't without challenges though. I mean, we had seen that we've talked about scale and being able to get to scale. Getting to scale is really important for the delivery system as well because until we really had the full magnitude of people in the model, they're really operating two business systems. One that lives in a deeper service world and one that is reimbursed for value where they're able to invest in prevention. This is new work for the payers as well to operationalize if it's prospective payment or an all-inclusive population-based payment or whatever other term that you want to use for really managing under a budget is what it comes down to. And this is all about sharing data too now with providers and how that exchange goes back and forth because as we've seen, it's really vital to be able to share, and that was kind of funny that I said vital. It's really important to be able to have that information to be able to make those decisions. Tom talked about the magnitude of our sixth closure for the hospital and I think we've come to the midpoint of the model where the risk exposure is growing, the investment needs are growing as well and really we've done our part in the ACL with trying to find risk mitigation plans for the hospitals. The founders have stepped up of the organization to be able to put in some plans for some of these smaller rural hospitals to be supportive of the model but it's hard to do that. And we really have to think about what are some of the other policy levers that we could be pulling at either the state or the federal government in order to allow them to continue on in this model. I do believe there are solutions. It's really going to take all of us coming together to be part of those solutions. And then we talked about making sure that the policy is in alignment, the timing pressures have been really tough. We talked earlier today about the attribution, not being finalized until March so we really don't know our complete budget till March. We are sitting here before you in October and we haven't had a discussion with the legislature yet about some of the investments that we're hoping to make. We've had those discussions with the agency of human services and CMMI but really the timing of all these events really has to be looked at to see is there a way to restructure things so that we're all marching in the same direction as we move along. And I know and I wanna give a lot of credit to the Green Mountain Fair Board that they did a survey earlier on this year to talk about what are some of those challenges to getting to scale to really achieve our ultimate goal and all of these came up. And so I think it's important that we continue these discussions together about how we can make this work because again, it's really gonna take a little bit to be able to move this workforce there. Thank you. So now that we've spent quite a bit of time talking about the finances, I get the pleasure of talking about all of the results of the great work that we're seeing across our unified provider network. So I wanna take you back first to the large number of $62 million and what I'm going to spend some time talking about are the investments that our providers are making in improving the care and outcomes for Vermonters across our state. As we know, one of the all-care model goals is about improving access to primary care and that's critically important to all of our providers. And so it's one of the things that we pay a lot of attention to. And here I'm showing you a couple of examples taken from different perspectives as we look at the Vermonters experience of primary care. So one of the things that we noticed when we asked Vermonters directly about their experience, about their access to care, that for children on Medicaid, their caregivers or adolescents themselves responding to these surveys indicate 94% of the time that they're very satisfied with their access to primary care. And for adults on both Medicaid and Medicare, that ranges from about 85 to 88%. And we know that we have challenges around the role nature of our state around access issues, workforce. So one of the things that our provider network has done through our Population Health Strategy Committee is to really have some discussions about where do we focus our efforts. And one of the areas, which hopefully makes tremendous sense to all of us in the room, is that we want to focus on our vulnerable populations, individuals that we think we could directly outreach and impact in a very short period of time by helping uncovered disease, by helping individuals better understand how to manage their own disease and connecting them to community-based resources and supports. So what we see when we've taken a look at our data for that vulnerable population in the first six months of 2018, about 85% of individuals in the Medicare population have had at least one encounter with primary care experience. And this year, so just 12 months later, we're seeing about a 6% increase. So now 91% of those Medicare individuals who have vulnerabilities related to their health and well-being have an experience in primary care. So I'm going to take a couple of moments and give you some stories from our local health service areas, from our communities that are serving individuals and populations. And so first I want to start down the southern part of the state in Brattleboro. And this is a really interesting story for me about collaboration across sectors. So in the Brattleboro Health Service area, they really focused on, again, the vulnerable populations, the vulnerable communities that they are serving and how to best proactively outreach and engage them in our care coordination programs. And as Vicki mentioned earlier, this isn't a phone call, a one-time experience. This is an ongoing relationship-building process. It often takes months to establish trust, to understand what is important to the individual in their life, and then to help identify the resources that could best support those goals that the individual is setting up. And so the teens are multidisciplinary. They often call upon different resources and expertise at different points in time. But in Brattleboro, what we're seeing is that 10 community organizations have come together. And in doing so, I'm going to talk you through these two graphs. So on the left, this is a graph where we're looking at the actual rate of individuals being admitted to the hospital in Brattleboro. And what we see, if you can track, I know that it's not dark, but if you look about two-thirds of the way across, you'll see that the line starts to sharply decrease. That doesn't late in the fall of 2018. Correspondingly, if you look at the graph on the right, here we're tracking the number of individuals that are actively engaged in our complex care program who have built those relationships. And again, if you look across the timeline, you'll see in that same window of time, late in the fall of 2018, the number of individuals active in our program starts to sharply increase. And so really what we're starting to see in this example is the direct impact of all of that time and energy of providers of all types pulling up their sleeves, working collaboratively to identify how can we support each individual in their unique circumstances? And then, how do we look as a community at how those systems and services are organized and how we can best then support the continued evolution of programs like this? In a second example, this time in the Berlin Health Service area, the teens at Central Vermont Medical Center identified an opportunity to help patients with diabetes. And the graph that I'll get to in a minute is specific to the Medicaid population, but the information and the experience transfers across the population in their community. They are treating individuals holistically, regardless of whether they are in the ACO or not. And so in this community, they focused on two key strategies. First, they were looking at what we call panel management. And what that really means is making sure that in the primary care provider's office, there is somebody who is responsible for looking ahead of time at the population, whether that be a population of individuals with a particular disease, individuals that haven't come in for visits, who meet screening appointments, and that they are making arrangements to help those individuals connect to services, oftentimes meaning coming into the office, but sometimes it means ordering a lab test or a procedure, encouraging them to follow up with a resource. The second strategy that they focused on in Central Vermont was aligning provider incentives. So they looked at actually the physician compensation plans and aligned the goals under the all payer model. So really quality goals and associated that with the physician's compensation. And those two strategies we can see now in this graph are really starting to pay off. So what the graph is showing us here is the percentage of patients, again this is Medicaid patients, that have diabetes who had a laboratory test to assess their blood sugar over the course of the last year. This display is also an example of how we're advancing our approach to how we share information with providers and help them understand opportunities to share the successes that might be happening in one community, to those that might be challenged or struggling in this area, in another community. So the green dotted line here, the green dots represent one care's average month to month and you'll see that that is increasing at a nice steady rate. The blue line however represents the experience in the Berlin Health Service area. And you can see over the course of the last, really close to 18 months now, they have had a continual improvement and they have maintained their performance well above the average of one care overall. And so part of our job then is to help shed the light on what they're doing that is different and help share that information with other communities so that we can then experience the best of those things that work as well as learn from the things that are tried that maybe aren't working as successfully so that we don't waste time and energy and resources in those directions but instead focus on the promising practices. These types of stories are things that we share every month through our clinical governance committees, through community visits and collaborating activities to be accountable communities for health. And so I think there's tremendous opportunity over the next couple of years of the all-payer model to shine more and more spotlights on these great successes. In the third example, this time we are looking at variation in use of the emergency department across our state. One of the things that I mentioned a moment ago was that it's always an interesting opportunity to hear from providers in our network about how they want to experience information and data in a way that's accessible and meaningful to them. So in this example, we're taking a visual look at what our performance looks like. The two maps on the left represent the Medicaid population on the right from Medicare. The very first map in Medicaid is looking at the rate of emergency department visits and the second map is comparing that to engagement in our complex care coordination program. That pattern is mirrored in Medicare. And specifically what we chose to look at in this example is having set clinical priority areas as a accountable care organization and communicated those out across our network consistently, are we seeing change happen relative to those priority areas? So the blue colors indicate communities for health service areas where we have seen improvement from 2018 to our 2019 year-to-date improvement. So knowing the calendar's not up yet. And orange represents an actual decline. The darker the shade of the color, the larger the scale of the improvement, for example. So what we're seeing here is that in that Medicaid map on the far left, eight of our health service areas have improved by at least 10% from their performance in the prior year when it comes to looking at how often individuals are going to be in the emergency department. I will note that where there are some opportunities where you're seeing some of the orange color as we've dug into that information, we can relate that back in many cases to reports from those communities around specific access issues in primary care where some providers have left in recent months and they are working very hard to recruit additional providers to that community. So I think that's an important note for us all to recognize and tie back to the underlying premise of the importance of primary care in providing preventive care, appropriate and timely access to services. Just pausing for a moment to recognize one care's unique value in providing data and timely information to providers of all types across our network. We have spent tremendous time asking providers what is most meaningful to you? How do we better support you with that information? And some of the things that we're learning are that it's helpful to break information down into small pieces. Now that sounds intuitive, but for those of us that like to experience all sorts of data and be able to play and learn from it, it's taken a little bit of reminding that here's an opportunity for us to be very focused and specific in asking and answering questions that providers want to need to know to better serve their patients. We have spent tremendous time adapting our tools, providing looks that start to dig into the variations of care and the patterns of care that might be experienced, say, across one care population to the next, the Russellian community to the next, and even down to the level of how does care vary from one provider to another within a practice organization? We send staff out into communities all of the time to help people understand the information and help them connect it to best practices and evidence-based guidelines for ideal care. And we use this information in our clinical governance committees and certainly at our board to help drive decision making both about opportunities as well as potentially successes around the population health investments that we're making. So one of the interesting areas of note is that when we look at our analytics tools, the software and the databases that we're using, we've actually doubled the number of organizations that are directly accessing that information to solve problems in their communities to answer both easy and complex and vexing questions that they might be facing. So I might move down to talk a little bit about our provider networks experience in the all-payer model and specifically our population health goals and some of the strategies one care has been deploying to support those goals. Again, I think it's really important to recognize that we take this from a frame of a unified approach to our provider network inclusive of primary care, specialty care, our home health agencies, our mental health agencies, as well as community-based organizations still nursing facilities. So it really is providers coming together both at the community level as well as at the statewide level seeking with one voice about what is important for patients and for patient care and outcomes. So just briefly, if we take this left right, we talk about access to primary care. We've spoken a little bit today about the investment in primary care. Looking to 2020, that is about $22.7 million invested into primary care to make sure that we are providing both preventive care as well as disease-specific care and referrals to resources as needed to support population health, the coordination of care, and better outcomes for Vermonters. A specific program that we are planning to advance in 2020 is our Comprehensive Payment Reform Program, or CPR. This is a program that specifically highlights the unique needs and opportunities for independent primary care practices and rewards high-value care. And as we continue to learn and receive feedback from providers in these types of programs, we continue to evolve them in new directions. And so some of the new directions for that program that are anticipated are really more directly tying some of the underlying funding to quality measures and outcomes as well as to advancements in the coordination of care for vulnerable Vermonters. In goal two, focusing on reducing drug debts related to suicide and drug overdose, one care has been very excited about a partnership that we've invested in between SASH and the Howard Center in the Burlington area that has embedded a mental health clinician into congregate housing sites in order to both reduce stigma associated with mental health as well as to reduce isolation. One care is committed to continuing this funding next year and we're very excited to see that there are some initial outcomes that we're starting to achieve that really look at not only the coordination and the holistic services that promote health and wellness both physical and mental within those settings, but also connecting those programs more proactively to reduce things like unnecessary utilization of the emergency room or more proactive use of preventive care and services. Also, this is an exciting opportunity for me to share with you a little bit about our innovation fund. And so new in 2019, one care's board invested more than a million dollars in a program or really a process that would highlight areas of promise and innovation at the local community level and provide funding to assess the impact of these promising ideas. So we're very early in the processes, but one of the examples of an investment that has been made in the program that is up and running is called psychiatric urgent care for kids. And this is a program down in the Bennington area, which is a partnership of United Counseling Service and Southwestern Vermont Medical Center. And their focus is on creating a child psychiatric urgent care center, which serves as an alternate source of care from care that was typically being provided in the hospital emergency room. And so what was happening was that individual children, often young children in elementary school, were experiencing dysregulation behavior that was challenging in the school setting that wasn't necessarily able to be appropriately addressed there and they were being transported oftentimes by police to the emergency room for services. And that community got together and said this does not feel like the best way to provide care for vulnerable children in our state. And so what can we do differently? And what they've already put in place and they launched at the beginning of this school year is a program that utilizes expertise of mental health providers who are used to caring for children with some of these concerns and doing that in a setting that is more accessible, more friendly, less trauma inducing. And so that is out of the hospital grounds in a safe and friendly environment with the goal of being able to help that child return to school that same day. And if not that day, certainly within the next few days, the program has run holistically involving parents and caregivers as well to help teach coping skills as well as supporting family strengths. And then as I move to goal three, we're really looking at the prevalence of chronic disease. And so when you think about the work of an accountable care organization, oftentimes a lot of time and energy is focused on chronic disease management. And that is certainly true here at One Cared in the state as well. And so some of the letters that we use are focusing on things like clinical education, having sessions where we are bringing experts together from the primary specialty care practices from our continuum of care, also hearing very specifically from patients and or caregivers who lived experience. And one of the interesting anecdotes I'll share is that in those sessions, which are often attended by 70 or 100 or more providers, it is usually that lived experience, the individual's experience with the delivery of care, with the relationships that they've formed, the way that it has impacted their health and well-being that really resonates the most for our providers. And so they take that back and they think about how do I incorporate those best practices into their workflows, into the way that they're delivering care. One final example here, also an innovation. This time in Addison County, we are very pleased to be able to support a program that is looking at how to better serve patients with diabetes. Oftentimes, individuals with diabetes need to have their eyes checked. And that often involves a separate specialist appointment, maybe traveling out of town, waiting for an appointment to be available.  And so in doing so, we're not only improving the satisfaction of individuals, the timeliness of the care that we're receiving, but we're also more likely to have those individuals receive the screening that is necessary because we've removed a barrier, whether that be transportation or time or busy schedules that we all face. So we're very excited to be monitoring that program and watching for the outcomes over the next year or two. I move forward. I want to spend a little bit of time talking about our complex care coordination program. In previous testimony, we spent tremendous time talking about the startup of this program, the tools and resources, how we were educating our providers around the network. And now I'm really excited to share some of the first outcomes that we're seeing from this investment. So as Vicki mentioned at the top of our discussion, we have in the last nine months, 10 months now, seen a six-fold increase in the number of individuals that are active in our care coordination programs. And just to put some numbers to that, we had about 500 individuals that were active in the program in January of 2019. And we keep watching this often on a daily basis. And as of the middle of October, we are now about 3,000 individuals statewide that are accessing this program, which means that they not only have the connection to resources and supports that can help them, but they actually have a plan for their care. They have goals set. They have people identified to help them make progress with those goals. You'll see that through the program where the 11,000 individuals have been touched. And you can see by the graph actually the rates of increasing engagement in care management or in care coordination over the course of this year. I think it's really compelling as we talk about our network of providers and recognize the unique skills, the license, the supports, the education that they have, that we now have 75 organizations representing more than 700 people on the ground in communities statewide helping to support the coordination of care for vulnerable reminders. That is a really impressive number in a short period of time. And I think it seeks very well to the spirit of collaboration across organizations within and again across communities in our state. We will continue to monitor a whole series of both process and outcome measures associated with this program, but I wanted to highlight just a couple of components now. So returning to the topic of primary care engagement, we first looked at those individuals in Medicaid and Medicare programs that are actively care managed. And then we dug in to see, for those that have been in the program at least six months, kind of our threshold of in the program long enough to see if this makes a difference, we've seen that 99% of both the Medicaid and Medicare populations active in care management have had a visit with their primary care provider office. And that's an impressive feat. It really speaks to the way that care is being organized. So that we see underneath that, that when we talk about care teams and the organization of the team around an individual that 86% of the time, they have a primary care team member listed as one of those core members of the team, if not the quarterback or the lead care coordinator. One of the earliest indicators from an outcomes perspective that we would expect to be watching, and in fact we are seeing, is what happens to the rate of the use of the emergency department for individuals that have this proactive care coordination and a plan around their care. And in fact what we're seeing for individuals, again that have been in the program at least six months, is a 33% reduction in use of the emergency room for the Medicare population and a 13% reduction for the Medicaid population. These are both highly statistically significant reductions and represent I think the first signals that we're expecting to see about the impact of this community team-based care process. In a second outcomes example, one of our partners, the University of Vermont health network, home health and, excuse me, home health at Hostos, I thought that would have run. They have focused some of the care coordination dollars that they were receiving from one care on experimenting with a program called the longitudinal care program. And what this really does is allows an individual who still has significant health needs, physical needs, mental health needs, maybe some social or economic challenges in their life who no longer would under a fee for service system traditionally be able to access ongoing home health services to in fact continue to receive them and to receive them in multiple and creative ways. So they can receive tele-monitoring in which they might have their blood pressure monitored from their home and that information sent to the nurse at the home health agency who then calls them up if something looks abnormal. They might continue to have visits by a nurse or by a social worker or by somebody in the community who is connected to other resources that can help with their individual needs. In this small pilot program, we've seen some incredibly dramatic results. We've seen an $1,150 per person per month reduction in cost associated with that individual's care. We've seen that the use of the hospital, so actually people getting admitted to the hospital in this program has been reduced by 26% and use of the emergency department has decreased by 20%. This was really exciting news to us and the kind of transformation and innovation that we want to see and promote. And so one of the things that we are committed to in 2020 is actually expanding this pilot program into nine additional health service areas, really being able to test this model in rural areas of the state and assess whether we can see outcomes that approach the magnitude of these outcomes in this initial population. As we advance through the years of the all-payer model, there are always opportunities to iterate, to learn from what we've done today and to improve upon that. And so at the direction of One Care's Board back last winter, we were then charged through the Population Health Strategy Committee with identifying what the appropriate next step should be to evolve the payment model associated with this complex care program. We understood that this was an opportunity to come together with partners across the state representing all different aspects of the continuum of care. And then our common goal was to figure out a strategy that would allow us to move from the initial capacity-based payments, so paying to make sure that there were individuals they are ready to really moving to a payment model that pays for value, one that is producing the results that we all believe are the right direction in providing better care and quality for Vermonters. We used an iterative process with multiple focus groups, lots of discussion, lots of disagreements along the way, lots of pushing to see how far could we go while not going too far so as to make this a model that was not sustainable on a month-to-month basis as organizations needed to meet their payroll and ensure that they had the staff able to provide these supports. The result was a consensus-based recommendation to One Care's Board of Managers back in the late spring, and we have spent the last few months traveling the state and speaking with leaders of all types across the state to help them get ready for this transformation. So what will be happening is in April of 2020, One Care will be evolving the way that it is going to share the $10 million that Tom was talking about earlier with providers across the network. And the new model is one in which we are paying significantly increased monthly amounts of money based on the individual care coordinator's role in supporting patients in the complex care program. So what I mean by that is if a person identifies that a individual, let's say a nurse from a home health agency is the person they want to be their least care coordinator, the quarterback of their team, they will get a payment for that role. If there are other people on the care team say a primary care practice and maybe somebody from the mental health agency, they will also get paid for those roles. In addition, when we look at best practices in care coordination, one of the opportunities our providers saw was to actually focus more on something called a care conference, really bringing together and convening the individual, the caregiver and family with those supports and organizations that had best then both build the plan of care together but also execute and evaluate the success and modify it as needed. And so there will be payments associated with the successful execution of those care conferences as we move forward. Finally, I think it's important to note that there was an active discussion and commitment that the organizations that were currently receiving funding under this model, including primary care, the area agencies on aging, the designated agencies for mental health and substance abuse, as well as home health would continue to receive funding. And that SASH was a very valued partner and in fact very engaged in our current program and that their funding would continue but be aligned under a central contract with one care. And then anyone who was brand new to the ACO in 2020 be given the same opportunity that those that joined earlier have to have some capacity building time in order to make sure that they can organize the services, free up the staff to provide the expertise and time that individuals need to best support these care plans and eventually the outcomes that we're all looking to achieve. So now as we look to 2020, I think it's important to recognize the scale growth that we've been talking about today that our goal here is to bring more Vermonters into an aligned model and for providers themselves to practice in one new value based system which increases the likelihood that all populations, whether they are within the ACO, under one care or not, receive the high quality care that we as Vermonters all want and deserve. This is realized through things like this complex care coordination program, through things like the innovation that we're discussing around geographic attribution of the Medicaid population. So as we turn to 2020, one of the things that we will be paying particular attention to is how we are continuing to monitor and evaluate the programs and investments as directed through our committees, our board around the value that we are delivering to Vermonters. In 2020, we hope to launch major new initiative, excuse me, a major new initiative that addresses Quadrate II. So this is the Quadrate in our population health model that focuses on individuals with chronic conditions. And we hope to do that by partnering clinical pharmacists as part of the primary care team and really looking at how we can use evidence-based models of practice that exist around the country to both extend that care team and focus on individuals who may need closer and better management of their conditions, including at times the way that they are receiving medications or managing multiple medications. As I mentioned earlier, one care plans to invest in spreading the Home Health Multitudinal Care Program to additional rural communities around the state. And we are making specific investments in mental health and innovation. So I spoke about a couple of examples earlier, but there are additional investments and programs that we are in the process of launching in partnership with Vermont Care Partners that are designated agencies around the state that are really looking at how we can address some of the needs of individuals that are accessing mental health care through the emergency department and how to help them navigate the systems, the resources that are needed in the community to help them avoid needing to access care in that site. We also are focused on continuing to improve engagement in primary care. So I spoke earlier about the focus today on the high and very high risk populations, our vulnerable populations, but we also need to pay attention to how we improve access to care more broadly and how we think about using our care teams in new and innovative ways to provide screening opportunities to promote prevention as well as to access care in all sorts of settings in communities where people are living, working, and playing. So as you're passing the mic, I just want to point out that it's called 15 Minutes Behind Schedule All Ready. So anything that you've done concisely would be great. I can be very concise. So I just want to close to say why are we doing this? I think it's important that we reflect on why we're doing this work. We're really doing this work because we want to have better health and wellness for the monitors, right? And we want to be able to have healthcare that is affordable and sustainable into the future. So we need to be able to curb some of that spending. What this budget really supports is those continued investments to advance the goals, those care goals that we talked about earlier in the discussion around access, prevention of suicide, and chronic diseases. We really want to be able to grow the model so that all of the monitors at one point in time can have the benefit of this enhanced system. Really looking at hospital payment reform as a crucial part of this so that they can be sustainable into the future. Primary care and community-based investments, they're really important to us as we look at the full continuum of care to fully wrap around individuals to support them the best way we can. And also, let's not forget, we don't want to lose any kind of momentum along the way and give up some of those valuable Medicare for current funding that absent the ACO wouldn't continue to exist. So with that, I leave you with an amazing quote and another testimonial from Jill Lord from Atlas Stutney Hospital who really kind of synthesizes what we're trying to do here. Instead of working in silos, we can approach this as a system. We're developing stronger relationships. Thank you. Thank you, thank you. I've had a number of requests for a wide array. Looking at the clock, I'm not sure that's the best use, but I do want to ask the corporate quarter how she's doing. We'll be there for the next hour and a half. Five minutes? Yeah. Okay, we'll take five minutes. Okay. Thank you for the more. I'm going to start with four questions. And Maureen, are you still on the line? Okay. How is your itinerary? Do you have a time constraint or? Okay, so I'm going to start with member Pella. Thank you. I'm going to be one here for in-depth presentation. I've been told by a couple of members up here to be quick and short. And definitely don't do any dancing. But that does make me turn to what? Rise from Mod because it was a Rise from Mod event that I got taught. So my question about Rise from Mod is I've seen it in Scott May. I've seen it at North Western. I've seen it in Southern Vermont. And I just wonder about at the upper level, at your level, whether or not you have any metrics that profile the connection of Rise from Mod to the areas of primary care physicians. Just thinking about somebody that comes into office, they're pre-diabetic, how does that physician steer them to the opportunities that Rise from Mod provides? Sarah, do you want to put that? Thank you for the question. I think it's actually really insightful as we think about spreading Rise from Mod activities into more communities. We've been very focused in the initial launch and update in working in cross-sector relationships within communities to build understanding and knowledge. I do think that there are many areas of strength as it pertains to the connection to primary care, but there are also some opportunities to continue to enhance that. And so that will require continued education, continued support of the local program managers in connecting to the resources within their community. One of the ways they can do that is through their local accountable community for health infrastructure. And as you likely know, that can look different from one community to the next. But I think it provides kind of a central organizing framework around how we can then best identify the strategies and the priorities to promote prevention activities and do it in ways that are creative and innovative and don't take lots of time and energy. And that's one of the key things that we've been so pleased to see in the Rise from Mod structure is around these amplified grants, taking the time to look at something that is the bright scene and a great idea and how a little bit of money can help amplify that and spread it more broadly. So I think as we move forward, we'll continue that with our primary care providers in more concentrated efforts as well. Thank you for that. My next question has to do with the choice of the trend rate in Medicaid. In the narrative, I think it's in the narrative, there was a discussion about a building a trend rate based on 2018 to 2019 experience now led you to about a 2.2% rate versus a 1.5% or 1% which I think was admittedly described as something very modest. And so in your models, you use the 1.5% or 1% rate. And I'm always a little bit concerned about the cost you have to kind of being a bit of a chronic disease within the healthcare system. And I'm just wondering what one of you are thinking about the choice having to do the 1.5% or 1.2%? Yeah, that's a really good question. So at the time that we're building the one care budget, we don't have information on the actual attributed lives. We don't have final information on the provider network either. So we try to make the best assumptions that we can to give the providers the opportunity to make a decision to participate that's reasonable and would give them a fair reflection of their downside risk, for example, and what they're published on management payments and big things like that. So we choose a relatively modest Medicaid increase for a couple of reasons. One is that all peer model holds us, still be heard? Yeah. Delta peer model holds us harmless to rate changes for Medicaid. That was one particular error in the contract that was noted. So if I were to project some rate changes, my concern is that in the evaluation of our overall trends, it would look like we're breaking the all peer model boundaries a little bit, even though some of that within is actually exempted from the growth trends. So that's one component. The other component is that many, when you actually go to the rate development with DVa and their actuaries, there's a lot of components, population-based components to it, demographic components, as well as the actual to be a lot to a certain sort of communities. There's just so many unknowns in there. So going to something that's been relatively middle of the road has been strange. Thank you. My next question has to do with the kind of growing portion of your revenues coming from McGruff-Washield and the QFP populations. And it's your booking revenues or projecting revenues at $167.7 million our last rate review with McGruff-Washield indicated that they have about $311 million worth of claims that they're projecting. So you were substantially into that market. And my question has to do with a review of the benchmark plan that is used for the QFP population. It really hasn't been, as I understand it, been looked at since 2014. And it's a plan where I thought with you today the silver proposal for McGruff-Washield for the 2020 bronze group. And it shows that Joe had diabetes and it was in a good appropriate care and approach. It would be about a $7,400 expense roughly. And the patient's share would be $4,000 to $5,000. So that's if you cross the line and become diabetic. If you're pre-diabetic, there's really not much in that benchmark plan for you. You can get a free preventive care visit that might tell you that you're pre-diabetic. You can pay $90 in the bronze plan for a visit with a nutrition. But the clinically based best approach of nutrition and physical fitness isn't there. And so that makes me wonder whether or not it's time to revisit the benchmark plan used for the QFP population and do so in a way that emphasizes the all-care model approach to investments in preventive care. That's a really good question. I'm not intimately familiar with this, the qualified health plan, benchmark plan that you referenced here. Totally interested in learning more about it and how we may be able to incorporate something in the all-care model. But I think I'll go back to, as a provider system, all the work that you heard about earlier is to prevent people from becoming diabetics or manage the diabetes better. And that has the potential to help that actual member save costs downstream. So very interested in learning more about that space. I'm almost certain that the actual real value of prevention is minimal relative to the value of the $7,400 a year of handling of treating diabetes. My next question has to do with thank you again for the profile of the $13.1 million in health care investments. There's always a lot of layers to this and I think that we went through the layers and diminished some of the concerns some folks might have with that number. I would just like to add that in the context of 2020, there are other numbers that affect some of your closest providers, the hospitals generally, where the dish payments have dropped over the last few years for a total of $14,700 down and the taxes from the hospital provider tax have gone up in 2020 from 2018 by $13.4 million. And I just think in terms of your presentation, you're looking at one small piece of the relationship with the state and in the entirety, there are a lot of relationships going on. And cumulatively, I'm never sure where they add up, but at the state level, I think they add up to a cost shift that we documented over $200 million just for Medicaid. So that's a point I would like to make. Two more quick questions I think, I'm trying to be as fast as I can. On salaries, you have, what is the rollout from 2019 into 2020 and what do you expect the fully loaded increases in 2020 to be in 2021? Well, we're actually rolling out new positions now in anticipation for the next year. I mean, demands are current. In terms of what 2021 looks like, it's hard to know at this point in time. It's one of those questions we evaluate through the year. Do we have the right resources in place? Do we need additional resources in certain areas? But just like any other business, we're very mindful of our financial resources and try to make decisions that allow us to support the network effectively and support the goals that all pair of model without being excessive. And my last question is having to do the proportion of your revenues coming in as fixed perspective payments. In our hospital budget for 2020, it was about $405 million of their $2.7 million that were identified as fixed perspective payments. Which is down around 15%. In your presentation, it's your like $471 million and that's at about 36% for the ACO system. You have in your presentation, I'm quoting here, when the point is briefed that most of the revenues are paid on a population basis, the underlying incentive to invest in prevention as well as to encourage the core business strategy for all of the state's providers. And I'm just kind of looking down the road here and wondering if you have any expectations of when the majority of payments will be based on fixed perspective payments and therefore we should begin to see that pressure in the system to help constrain cost of rate payers and tax payers. I'll start. I think the prospect of the fixed perspective payment with Blue Cross is a huge support and opportunity for us. So that will certainly help change that pie a little bit. There's a lot of other payers out there as well. So if I'm honest about the barriers, it's just a multitude of payers that contribute to the healthcare system and converting them all to a fixed payment in a relatively short period of time, this little bit of a daunting task. Really the goal that we think about and this relates to Vicki's comment about two different business models is we have the preponderance in a fixed payment capitation model and then the fee for service volume-based reimbursement is a smaller portion of the business and the decisions are made based on the larger intersection. That's what we're trying to achieve. It's never gonna be a hundred percent but we're still trying to get that balance to provide us with more of their revenues in a fixed payment model. I would just add to what Tom said in terms of when do we think we will really reach that threshold and I would say that some of it depends as well, right? So when I say it depends, I say it depends because right now the Medicare or inclusive population-based payment is not indeed a true fixed payment. Really what it is is it provides you with that fixed payment up front and then it reconciles on the back end fee for service. That's not predictable or sustainable. So really what we need to do is move our federal partners to a place so that they can make that a true fixed payment and be able to do it in a reliable way for our hospital partners. And we also have one of the challenges that the Medicare risk corridor for some of the smaller rural hospitals right now is very large and it's not feasible for them to be able to do that. So I think one of the biggest challenges for us all to solve for in this room is how do we enable more providers to sign up with the Medicare program and how do we get them to truly fix payment? Great problem. I'm going to start work. We just left off and I'm just going to apologize in advance because I have questions throughout a bunch of different materials that we might get a little redundant as I flip through things, I might apologize. On the Medicare risk corridor for the rural hospitals, as I think you know, the legislature passed a rural health services task force last year that has 14 members across the provider spectrum and I am the chair on behalf of the Green Mountain Care Board and so me as a task force have been starting to delve into the issues that are at the top of mind for our rural health system in terms of sustainability. So I was curious to know if you have any suggestions around the Medicare risk border specifically that could help bring along the rural or small hospitals, understanding of course that that's something that the federal partners would have to agree to which means a negotiation and that's not quick but I'm curious if you've done some thinking about how that can evolve. I've done a lot of thinking about how this can evolve and I think your right to separate it into different components and the first one at the top is the risk corridor with Medicare which is at minimum 5% and that's a pretty significant amount and for rural, pretty complex hospitals that's a very significant amount. So that's one topic I'd like to address over the next years. How do we still maintain some data outside the risk which I believe is effective in driving the change that we'd like to see but make it a little bit better fit with Vermont economics and health care? The other just to name it is the one care risk sharing model and we put a lot of thought into this and I think it's something that we intend to look at really closely over the next few months certainly four network commitments are due next summer and the problem that exists is it's a zero sum game within our ACO. We have a risk number that needs to be delegated in some way somehow across the network. There are lots of ways to do it but at the end of the day some are gonna end up if we make a chance with more and some will end up with less. That might be right and might be okay to do but it needs to be done really thoughtfully with our network participants in advance on their decisions to participate. So that's something that I'm really wanna look at closely throughout the over the next few months just to make sure that we evolve with our network and can get the maximum participation there. Thank you and I should also mention Sarah came to one of our care coordination topical meetings and that was very helpful and we do have a care coordination subgroup that will have some recommendations that will come out. Shifting now to the fixed payment issue for this will come as no surprise to you since I asked this question pretty much every year but I was delighted to hear that Blue Cross was moving forward with a pilot on a fixed perspective payment and I was curious if you could give me more details about that. Are we looking at one partner, more than one partner at the hospital side? Do we know who that is yet? It's a great question and yeah, thank you to Blue Cross for investing the time and energy to develop that is much appreciated and something that we're excited about as well. Southwestern Vermont Medical Center has agreed to be a pilot site with us and test out some of the mechanics so a big thank you to them as well. We're working with University of Vermont Health Network sites and trying to work around their epic installation dates a little bit to make sure that we just don't have too many competing demands but we anticipate some kind of iterative rollout within the UVM Health Network in 2021. I wanted to talk with you more about is attribution methodology. So, hey Chair. So in your materials, which is in part two of the binder, you had some information around potential opportunities about attribution, specifically on page 13, you had a grid that provides attribution opportunity targets in 2022 and I know that you had indicated earlier that in the budget numbers, you didn't include any assumptions in the expansion of the Medicaid geographic attribution but I was curious about this chart and in terms of the opportunities, are these related to assumptions around geographic attribution, other attribution changes, inclusion of new providers? What's driving that chart? Yeah, good question. So, I took to use the word targets pretty literally when I developed this chart and did incorporate factors for geographic attribution what I think it could yield on a per payer basis and our experience in that particular area is limited but growing so I think a lot better understanding of what the opportunity actually is in the future and then also just looking at the size of each community, what do we compare to another similar or like size community? What might the attribution opportunity be for that particular community? So it's, I think it was a good fair stab at what we think is out there but it was really based on our past experience and just matching up with similar, similar configured communities. Great. And so did you make any assumptions of geographic attribution? Were you just thinking about Medicaid or were you thinking that that's a potential for other payers? In particular, I'm interested around Medicare. Well, we're starting with Medicaid as a partner also interested in this model and I think what we're learning in Medicare is very transferable to other payers. Medicare would be another one to consider, I think, and this is, I said I think because we're still learning in this space. I think the opportunity is greatest in the Medicaid so we're almost tackling the biggest one first, Medicare. The percentage that actually attributes much higher because the engagement in primary care is just much more regular. I would just add a little bit to that in that if you're looking at Medicare usually these are individuals who haven't been seen by a primary care physician or have, they're seeing another provider in our network and so when we're looking at the magnitude of risk too since we don't have a lot of experience with those particular individuals we have to have a discussion with Medicare of could you add some sort of tiered risk approach to that instead of the normal 5% risk formula because I think that would be prohibited to scale in that model. And in terms of the Medicaid geographic attribution are you expecting to have more data or information about that program at some point in land? Would you expect to have that? So I guess that's one of the things we're working very closely with Medicaid on now. Our plan, it's always a plan place, is that we would be able to close up those discussions around December when Medicaid also wants to come in and have their actual review done on their rate so that could be part of the rate discussion. Turning a moment to the comprehensive payment reform pilot, I was very interested to hear that you were looking to add quality measures. I wonder if you could give me a little more information about that. How many are you looking at? Are they aligned with the ACO quality metrics? How are you engaging with providers around administrative for that kind of thing? Sure, so we engage the independent primary care providers that are currently in the comprehensive payment reform program in a series of conversations as we look to increase accountability under that program as we move to 2020. And so what we are looking at is a program that creates a variable component of payment associated with meeting our target care coordination engagement rate of 15%. So that would be one component. And then a series of quality measures that we've agreed upon with them. And within each of them, we looked at by payer, what does performance look like at the ACO level or down to the individual site level where we can do that and we set targets for them. The measures do vary a little bit. So sometimes, for example, in a measure that might be related to a particular chronic disease that would normally require manual data collection on our part, we kind of came to some compromises where they can run panel management reports out of their EHRs and send us that information and we use that at a population level as a proxy for their performance against targets. So we'd be happy to provide you with some additional details on the specifics of that. Great, and it sounds like that shift to allow for the EHR report is really trying to attack the administrative person issue that we often hear related to quality. Absolutely, we're really trying to find the efficiencies and these are proxy measures. We still will have our quality measures at the broad one care level, but we think there are reasonable estimates on a monthly or quarterly basis to signal the change that we want to see. Great, thank you. I was curious, this may be a bit of a sensitive question, but I was curious if you could speak a little bit to the situation with Springfield Hospital as is known, Springfield has moved into his file for bankruptcy and moved out of t