on the agenda is the executive director's report. Susan Barrett. Yes, I have a very brief executive director. I want to remind folks that we are going on the road next week. We're going down to Mount Staten Hospital in Old Brugnese, Wisconsin, in the end of winter, right? So we'll be there for our board meeting. We'll also be visiting some community providers in the upper valley. So if you're available, take over the trip with us. The other thing I'd like to announce is if folks could sign in, as out on the table in the entrance, if you could just make sure you sign in. And that's all I have to record today. So before we go to the next item, which is the minutes, Mike and Melissa, can you get set up? So the next item are the minutes of October 17. Is there a motion? So moved. It's been moved and seconded to approve the minutes of Wednesday, October 17. Without any additions, deletions, or corrections. Is there any discussion? Seeing none, all in favor signify by saying aye. Aye. Any opposed? OK. Moving right along. We're going to turn it over to Mike and Melissa to give us an intro into the one-care Vermont budget presentation that we're about to dissipate in. OK, thank you. For the record, my name is Michael Barber, Chief of Health Policy at the Green Mountain Care Board. And to my right is Melissa Miles, Health Policy Project Director for the board. And so we're just going to do a fairly brief introduction to the hearing on one-care Vermont's fiscal year 2019 budget. So this is the schedule for this afternoon. We're going to try and keep our introductory remarks to less than 15 minutes. One-care will have an hour for their presentation. There's an hour for board members to ask questions and for questions potentially from Jackie Lee from Lewis and Ellis, who hopefully is on the phone. Then the health care advocate will have 30 minutes to ask questions. And lastly, the lead time for public comment. I would also note that the board does accept written public comments via its website at any time. That's up and running currently. So since you are just coming off of the hospital budget season, we thought it would be good to just step back for a second and revisit the theory behind the all-payer accountable care organization model. And this slide is trying to show you that the all-payer model is an attempt to solve a problem, one that is not unique to Vermont for sure. And the problem is that the cost of health care is increasing at an unsustainable rate. And there's room to improve both the health of Vermonters and the quality of care that they receive. One strategy for solving this problem is to have providers from across the continuum work together to deliver care in a more integrated and coordinated way, to focus more on primary care and prevention, to deliver care in lower-cost settings where appropriate, and to reduce duplication of services. To incentivize and facilitate the kinds of changes in the way care is delivered, the other part of the strategy is to change the way that we pay for health care, to move away from a fee-for-service payment model that rewards providers for delivering more services and to move towards population-based payments where providers accept responsibility for the health of a group of patients in exchange for a set amount of money. The hypothesis is this will be a more predictable and sustainable financial model for payers and providers. We'll spur providers to work together in new ways and we'll give providers flexibility to make choices in investments that make sense for their patients, but that might not have made sense, financial sense at least in a fee-for-service world. The state chose to implement this strategy through a statewide accountable care organization model in which the majority of our monitors are served under ACO programs that are aligned with one another so that providers have clear and consistent incentives. Under this model, ACOs are supposed to be the vehicle for change. They're supposed to help providers succeed in managing this transformation by providing support, data, analytics, and sometimes by shifting money to areas that need it most. As you know, the All-Payer Model Agreement signed in 2016 enabled Medicare to participate in this kind of model. We are pretty early in the implementation of the model, 2018 being the first performance year. However, for 2018, we have four fairly well-aligned ACO payer programs in place, serving approximately 112,000 Vermonters, which is a major step, but short of where we are supposed to be under the agreement in terms of scale. This graphic is meant to build on the last slide and just illustrate that the payment reforms really reinforce and enable the transformations in care delivery with the ultimate goal being to achieve improvements in health and slower cost growth. A key concept here is that when you put providers at risk for the cost and quality of care delivered to patients, it will spur increased investments in focus on primary care and prevention since there is a consensus that strong primary care foundation with an enhanced focus on preventive services can improve health care quality, improve the health of the population, and keep costs down. The last column here describes the three population health goals that are found in the all-payer model agreement. And these are the, again, population level outcomes that Vermont is trying to positively impact through the model. And this slide is to very briefly remind you of what Vermont is responsible for under the all payer model agreement, because you can and should consider relevant requirements of the all-payer model agreement when you're reviewing and approving an ACO's budget. The requirements in the agreement generally relate to cost, cost growth rather, alignment of programs, scale, and quality. With respect to cost, the state is responsible for limiting all-payer cost growth to below a compound annual growth rate of 3.5% over the five-year term of the agreement. It is also responsible for limiting Medicare cost growth to 0.2% below national projections based on what happened last year. The state is responsible for ensuring the alignment of payer programs in certain key areas, specifically attribution, attribution services included for determining shared savings or losses, risk arrangements, and quality. The state is also expected to meet fairly aggressive scale targets or targets for the percentages of people that are attributed to the ACO or an ACO participating in the model. And finally, the state is responsible for meeting 20 different quality measures that are tied to and built up to the three overarching population health goals that you saw in the last slide, improving access to primary care, reducing deaths due to suicide and drug overdose, and reducing the prevalence and morbidity of chronic disease. This slide shows the regulatory levers you have in which to operate at the level of the ACO. Obviously, you have responsibility for reviewing ACO budgets and payer programs. You also have the ACO certification responsibility, which all fell under Act 113. We did certify one care earlier this year, and we've asked them to provide us documents so that we can review their continued eligibility for certification. We are in the process of reviewing those, but that is not the subject of today's conversation. So finally, you have the ability to work with Medicare on designing an ACO program for 2019 and to establish the benchmark or financial targets for the ACO in that program. So we made some decisions on the design of the Medicare program earlier this year, and there will be a few more decisions that will be coming back to you in the coming weeks. So the Medicare benchmark and Medicare Raider intertwined with the ACO budget process, and I imagine one care will touch on the Medicare rate in their presentation today. There we go, it wasn't moving. This is the budget review criteria, asset 4th and 18 BSA 93 82B. Many of the criteria relate to the strategy that underlies the all payer model, and this is not an exact list, but it gives highlights that we certainly look for when we are reviewing the budgets. So one example is how the ACO is working to prevent duplication of services and integrating with the blueprint for health and communities. Another is how the ACO plans to invest in primary care and community based services and to promote seamless coordination of care and address social determinants of health. We also need to consider how the ACO supporting improved population health outcomes and also rewarding healthy lifestyle choices. And finally, while these are the statutory criteria, as Mike mentioned, a few slides back under the rule, you should also consider any relevant requirements of the all payer model agreement. I wanted to say on the last slide that the board is supposed to ensure that an ACO has in place a financial guarantee sufficient to cover its potential losses. This is actually a requirement of certification, but it's something that we are looking at during the budget process. The way that this is done under rule five is that an ACO has to propose a maximum amount of risk that it wants to accept in the upcoming year and has to provide the board with a plan for how to manage that risk. Then the board then approves that maximum risk amount as part of the ACO's budget. I wanted to highlight several of the ACO budget order items that the board ended up approving on December 21st in 2018. Sorry, 2017. 2017 for the 2018 budget. These are some of the items, but they are not limited to a maximum downside risk, risk corridors that averaged about 4% among all the payers, a reserve requirement of 2.2 million, an administrative expense ratio that did not exceed 2%. Population health investments that did not go below 3% of their total budget, and that was an estimated 25 million at the beginning of last year, subject to change. The Medicare rate of growth was 3.5 for 2018. We also looked at all of the scale target ACO initiatives that they had among the four payers by which they're contracting with this year. So finally, this is the timeline that we have been working under. We've been reviewing since October 1st, one carers budget. Today is our hearing, and we are hoping to be able to adhere to this timeline, but as you'll see, we do have potential votes for November 28th and December 3rd. We are waiting for some information that has not been finalized at this time from both Medicaid for Lewis and Ellis to be able to complete the Medicaid advisory rate case that is in statute. And there are some unknowns still that one care may speak to also in terms of their self-funded programs for 19 and the commercial QHP program. So we're doing our best to work within this timeframe, but we may need to come back to you with an adjustment. And that's it. Any questions for Mike or Melissa? Just on the timeline, and my recollection is that the relevant really legal document that would impact any timing issues would be requirements around the Medicare rate, but am I forgetting anything? Or do we have some flexibility there? You're memory correctly. So the all-payer ACO model agreement requires that we submit a rate to CMS 30 days prior to the beginning of the performance year. So that would put us at the end of November. We would like to meet that, but we do have some flexibility if we need it. Thank you. And last year, we waited an extra two weeks for the information, correct? That's correct. This year, we will be getting the Medicare final information by, I believe, November 9th. So that shouldn't be an issue this year. I think Medicare is on track to give us what we need. We are behind where we thought we would be in terms of getting information from Diva for the Medicaid rate case. And there's a lot of other uncertainty in the budget that may lead us to try and push this back a little bit. It's okay. Great. Any other questions? Okay, thank you very much. Todd and Woodpecker team, if you could come down. At this point, I would ask the court reporter to swear in those who are at the table. And Todd, is there anybody in the audience that you're gonna have offer any testimony? None of you have a point. Okay. If you swear this testimony, you're about to hear will be the truth, the whole truth and not the truth. Yes, yes. All right, thank you. I do want to introduce Kevin Stone is here, who is the chair of the One Care Board and made the trip up to me in the audience. So thank you for being here, Kevin. I just want to, as ways introduction, say that I'm Todd Moore, CEO of One Care Vermont. And I'm here with team members, Tom Boris, director of finance, Sarah Berry, director of clinical and quality, and Karen Lee, our vice president of finance. Be the four of us that will be doing the presentation for you today. A lot of it will be Tom and Sarah doing the bulk of the presentation slides with Karen and I offering more commentary at certain points and in response to questions. I do want to just put a couple things in context before we get going, which is we're still early in this all-payer model and it continues to be quite a worthwhile but complex journey to understand how this should work and will work and the all-payer model agreement doesn't answer all the questions that get into the details of our budgets and programs or even your regulatory standing over it. But I do want to thank Michael and Melissa as well as Susan and the rest of the Green Mountain Care Board staff for really being in the trenches with us trying to figure this out and work our way through how this model should work and is supposed to work. So I would envision today as it really is a dialogue and there may be some things that we need to put in a parking lot for more discussion between us and your staff or with the board. We're gonna do our best to sort of explain the way we were thinking about how next year ought to work in our budget with your regulatory levers and review criteria in mind. You know, certainly we're here to answer any questions that you have as we move through this. The other part of the introduction is that, you know, a budget is just a plan and I urge you to view this budget the way you might envision a hospital budget that there's certain parameters that you need to have. You need to understand what our plan is. You do need to ask us to come back next year during the year to say how are we doing against the plan and are we implementing it as we said we would. But a lot of this is very dynamic and we don't know until after, you know, the new year who's really the attributed lives and what some of the actuarial models end up being for the actual accountability that we have. And that's just part of what happens here. And certainly in that one care holds different contracts with directly with Medicare, but with a lot of standing by the board to set those parameters, but also a completely independent contract with Medicaid and with commercial carriers, that this regulated but yet individual contracts held by one care with the different payers and programs, you know, is part of what we're all trying to figure out is how do we, you know, build in the appropriate flexibility within a budget to anticipate the fact that things do change. So I really appreciate the board's flexibility and respect last year in getting to a point that we could get this thing launched. And I would hope that we'd have a similar approach heading in to this cycle. So with that introduction, I think we're ready to get into the PowerPoint. Okay, last year I gave you a checkbox list of what was in the budget as the big headlines. I'm gonna do that again this year. I think we've got a great story for more progress in all payer model in terms of an expanded provider network, expanded payers, expanded attribution, and you know, really fulfilling in our plan what an all payer model ought to be, which is including populations for Medicare, Medicaid, employer based plans and insured plans on our qualified health plan exchange. You know, we are continuing down the pathway of expanding hospital payment reform of the kind that we've set precedent for and often, you know, I think that story gets missed of, you know, we're doing the most advanced hospital payment reform, real payment reform in the country with the fixed perspective payment for Medicare and Medicaid. Continued physician community investment and payment reform. We're building, we're maintaining and even building on the great models that we've got in place now and you're gonna hear a lot about that story here today. In advancing population health management, you'll hear from Sarah Berry, you know, how we continue to fulfill the promise of having a plan for every patient as part of this. Yeah, that's in an effort to do well under the economic model, but it's really the right thing to do to have a more coordinated system and a more proactive system that keeps people healthy rather than only treat them when they're sick. So you're gonna hear about all these things I hear over the next hour from my team. I did include a slide that I've used a couple of times in other presentations for those to explain what's in a ACO budget in Vermont under an all-payer model and with the Greenmount Care Board oversight. This slide, oddly enough, looks way more complex and busy than it is and I'm usually just the opposite. So really, at the end of the day, what's in the budget are those two blue boxes, which is what is our total cost of care targets for the attributed population that we have and what is our infrastructure and investments and payment reform elements that we're funding outside of that, including the operations of one care. And what you're gonna hear from Tom is $851 million for our projected spend for the attributed lives next year across all payer programs. $53 million in payment reform, community investments and infrastructure to support the model. You're gonna hear about how to the $53 million of that investment, that it's about 29 million coming from hospitals and 26 million coming from payers in the state of Vermont through a variety of methods and that is one question I often get asked. And those monies fund the things that are down in the lower right, which is some of the great things that maintain the blueprint payments, support community health teams, do real payment reform for physicians, bring in community-based organizations and designated agencies and support communities and innovations and all the infrastructure to administer it. So, Tom, you're saying that of the $53 million, you've got 29 to 26, which adds up to 55. What am I missing? Oh, good question. What number's wrong, Tom? It's probably just a rounding thing. We'll look at it as we get deeper and have more of a detail. Thanks. On the left in the yellow box is the risk and that is the one thing that sort of is this unique factor is our budget pretty much projects what we think is really gonna happen from an actuarial predictability standpoint to our best ability to predict actuarial outcomes, which isn't that easy. So at the end of the day, on top of everything else, you will hear about what is our projection against that target, but also what is the maximum risk or reward that we could get under these programs. And that's on total cost of care and the risk-bearing entities in this model. Again, for next year are the hospitals participating in one care, bearing risk for all local attributed lives, whether they employ the primary care that attributed those lives or not. For our payment reform, the way our programs work is the payers in programs, Medicare, Medicaid and commercial carriers still pay fee for service for most providers, whether they're in the network or outside of the network or even outside of Vermont. It's really a short list of providers that we, at one care, actually get access to funds from the premium for us to make the payments to the providers and implement the reform. And it's really only two types of providers, one the hospitals and the network under the hospital payment reform model of the fixed perspective payment that I talked about a minute ago. And the independent primary care practices who participate in our CPR, comprehensive payment reform model where they get a monthly blended capitation across payer programs. So we are gonna see, we had three in the CPR program this year, we're gonna expand that to I believe five next year and the hospitals will continue to all be operating for Medicare and Medicaid under the fixed perspective payment program. So that in a nutshell really sort of shows you what you're gonna hear about over the next hour and gives you a feel for how this works. All right. So my job today is really just to guide you through the whole one care budget model, how it comes together, have a strategy that hopefully will work well for doing that. There's a lot of content here. I'm gonna try to go through quickly enough to be mindful of our one hour time but if there's something I'm saying that just doesn't compute, please, please stop me and we'll circle back. But just to start, we're gonna hit some high level overview points that are really the basis of everything that will follow. And first things first are the payer programs that are included in the 2019 budget model. Starting with Medicare, this would be the second year of a Medicare risk program. Interesting note here is that we're moving from a modified next generation program in 2018 to a brand new Medicare program called the Vermont Medicare ACO Initiative. Medicare has a number of different program offerings along a spectrum of reform and progression. This is a brand new one that Medicare is offering and we're modeling us as being an N of one in this new program. Medicaid, this will be the third year of a risk program with Medicaid and is becoming a very nice, stable program for one care. Every year that we're in this becomes easier and easier and I can attest to that personally. Also including a Blue Cross, Blue Shield, QHP program, risk program for the second year to add that continuity to the network and the program offerings. And we also are modeling a continued pilot with the University of Vermont Medical Center to include their self-funded plan in our model. The last section here is a self-funded expansion. This is an area of opportunity and growth for one care. And we're intending to grow in two different ways in the budget. One is to build upon the UVM employer plan model and roll in other employer plans into the programs. And the second approach that we're taking is to work through plan administrators to bring in a larger book of their business under one contract with one care. This has some efficiency in that we have one relationship with a plan administrator that can bring in multiple employers with one swoop. The next slide shows our year-to-year network participation growth by community. You'll see in 2017 our four original Vermont Medicaid next generation participants and then growing substantially into 2018 and then continued growth into 2019. The two notes here to make are that we have two communities that are moving from the Medicaid only on ramp to a participant in all three risk programs which is a very positive sign. We're definitely trying to continue to move these communities into all risk programs for the scale and for the continuity of value-based care in their community. We also have three brand new communities entering the model in 2019. That is Rutland, St. Johnsbury and Randolph. They are participating in the Medicaid only option. This has proven to be a successful strategy to on-ramp communities, get a little bit of comfort in the Medicaid program and then hopefully transition them to all risk programs in 2020. One other note here is North Country is staying as a Medicaid only HSA for this year and that's due in large part to a recent leadership change. I like this slide to really just show visually the different provider types that make up our network. We speak a lot about the hospitals but there's really a wide array of providers that participate in our programs. The first three categories, the hospitals, FQHC and independent primary care is really where our attribution comes from but you can also see from all the remaining columns that there's a number of other provider types that don't specifically attribute to the model but are integral to our health systems and important to keep in our model. All right, attribution estimates. We have this broken down by payer category. So starting with Medicare, modeling an anticipated 47,000 attributed lives sets up about 10,000 from the current year starting point. Medicaid, we have just shy of 67,000. A lot of growth in those new communities that are coming on the Rutland, St. John's Berry and Randolph HSAs. Blue Cross QHPs, anticipating starting the year about 22 and a half thousand. We'll see all of these, we'll see where they land when the initial attribution runs, when they come through and then self-funded, this is really the biggest area of growth is up at just shy of 36,000 lives and that includes the expansion of the UVM pilot to other plans and the other model that I spoke about where we're working with a TPA, a third party administrator essentially to bring lives into the program. When I think about the attribution list and what this is for means it helps all the calculations downstream so it's a basis for calculating the total cost of care numbers that we'll have and the PHA and population health management receipts that are expected from the different providers in the network. And ultimately these attribution runs happen in December or into actually 2019 when the final numbers come in but we use our modeling data and the best available data we have to build our expected attribution numbers. So to round this first section out a little bit we have our network development strategy. Really the summer months are when we engage with prospective new participants in the network and develop our idea and strategy for how we get more and more participation and expand this statewide model. Really in this year we focused on the FQHC participation, we focused on getting the HSAs that did not participate in 2018 into the model. I'm relatively pleased with the way that all went and I think our vision looking forward is to round out HSA participation so that we have all the Vermont communities in some sort of a program. Help to transition HSAs that are in the Medicaid only path into all three risk programs or four risk programs if you include self-funded. And then also developing our programs to look at how we integrate better integrate specialists and mental health providers into our clinical models so that we're adding value across the full spectrum of providers. All right, budget breakdown. My approach to this is going to be to follow the income statement. So for those that have our budget submission memory serves me well, it's appendix 4.2. And that has really our illustrative income statement for one care, different revenue streams that we have and I'll use revenue in the term quotes, I'll explain that a little bit later. And then the different expenses that flow through one care. So I'm gonna go section by section and speak to each about what's our philosophy and approach and how we have come up with the numbers we're presenting today. So the first section is in the revenue block and these are the total cost of care targets. This is gonna reference back to that $851 million number that Todd referenced on the very beginning of the presentation. These are the targets of accountability. This is the spend expectation for each of these programs and I'll explain how we come up with each of these now. So just to baseline on the general approach, our philosophy is to project the total cost of care targets in a manner that is either and or actually sound using the best data we have and also connects in any ties to contracts. And the big example is the all payer model which dictates some of the Medicare components. So we're trying to use a little bit of the best of both or the most appropriate to come up with our best guess for these total cost of care targets. These numbers are important because they ultimately drive what the downside risk or upside potential is for each of the hospitals. So we put a lot of effort into making sure that we're doing the best we can to project these. But I will note that ultimately, in particular for the Medicaid and Blue Cross and the self-funded programs, they're negotiated between one care and the payer. Those negotiations are ongoing. So the numbers in here are our best estimate of where we think these targets will land. So start with Medicare. Medicare is an interesting one in that the all payer model really dictates the methodology and the Green Mount Care Board. The methodology that is applied to come up with what the 2019 expected benchmark or target will be. We are modeling our expected benchmark in a manner that we believe is faithful to the model in the all payer model agreement, which takes the current year, which is 2018 spend and trends that forward using a trend rate per the Vermont all payer model that happens to be 3.8% in this trend model and carries forward any expected shared savings from 2018 year into the 2019 year. That's the methodology by which we keep that connection back to year zero of the Vermont all payer model. We do have some anticipated shared savings carryover. That is in part due to the conservatism that was built into our 2018 target so that we could continue funding some of the blueprint programs in the state. As we look at the trend chart here, I do want to point out some interesting things. Early on, the green line that you'll see is our actual spend and just as a note here, this is going to be a mix of shared savings results and a mix of all payer model results with some slightly different networks so there's a noise in that, but I think the messaging is so important. The shared savings calculations of benchmark never really worked that well for our state. There are both national and regional adjusters that resulted in benchmarks that were well below what we expected to see for spend. The Vermont all payer model provides a much better basis for setting up benchmark uses and much more current base shared savings actually looked all the way back to 2014, whereas the Vermont all payer model uses the previous year and is based on our actual network and their actual spend. So the basis on which the target is built is much more relevant to our economics and you can see that increase that was seen in the gray line from 2017 to 18 and then 18 to 19 is a much more reflective of our expected spend in the state. Without some of these modifications, it's questionable whether or not we could enter, recently, just to find the enter into a risk program with Medicare. So the 17-18 includes both the 3.5% floor growth rate and the blueprint conservatism. So that wasn't included in the base in 17 on this particular graph. So that was the basis of that being increased. All right, next we have the Medicaid, again, Medicaid's negotiated program and we really have a more stable base of data upon which to build these targets which adds confidence, certainly to our model. And we're using the 17 spend and very conservative trends that are yet to be negotiated with Diva to come up with what we think the expected 2019 benchmark will be right now using 1.5% for that from the 2018 to 19 mark. We do incorporate, because we've been in this program for a couple of years, we do incorporate our actual current year performance. It's relevant, important data. We also get modeling data from Medicaid and we do our best to blend these and come up with the targets that are as reasonable as we can get them to be. This program, just like the Medicare program, includes that 0.2% discount factor built in. Next we have our Blue Cross Dushio Vermont QHP total cost of care target. We are generating this target by using the 2017 spend and we're doing this all based on a loud amount and projecting that forward using training rates per the Blue Cross Green Mountain Care Board approved finally and that is how we get from a 2017 spend number up to the 2019 projection. We're in negotiations with Blue Cross to really finalize both the methodology and what the real number will be. This right here represents our best estimate of a fair approach to get to a 19 benchmark and ultimately we'll be determined in collaboration with Blue Cross. Just to go into the Blue Cross trend rate a little bit deeper as it's an interesting one and a little bit more nuanced perhaps than some of the others is we build a trend off of the Green Mountain Care Board approved rate filings but really are zeroing in on the factors that affect claims costs and some of the factors that affect premiums don't necessarily translate directly down to the expected claims spend so we try to zero in the best we can on the factors that really would affect the server's equivalent value of the care for our tribute lives. One factor that we do have built in here is a 2.3% adjustment for the AHP Association Health Plan transition that came up in the negotiation for the trend rate filing of Blue Cross. We need it to be reasonable and that type of migration of LDR patients from the QHP market to the Association Health Plan market can increase the costs on a PNCAN basis and these are the type of factors that we're looking at when determining what's a fair benchmark for the ACO. We're excluding any factors in the trend rate filing that are related to non-claims components such as administrative costs or building of reserves for Blue Cross or any other Blue Cross tax or B impact adjustments. Next we have our self-funded total cost of care data arm limited for this program. We're building this model largely based on the current self-funded model that we have but we will be hopefully bringing in new plans and also a plan with a third party administrator that will affect these but just to put in a placeholder of what the expected spend might be showing some trends here. Really there's a lot of opportunity in terms of scale to grab more and more self-funded so it's an area we focus on a lot and want to continue to work on it more and find more employer plans and more plan administrators who have to participate with us in these models. All right, slide 20 for those of you who are objecting to one. We have the estimated total cost of care targets in aggregate. This slide isn't intended to show trend rates but really the scope of claims costs that is now within our accountability at one care. We're moving from a projected total cost of care and safe projection because it is based on attribution and attrition of the experience. We expect a 2018 total cost of care of 635 million moving to 851 million so that's an additional 34% accountability in the one care model or 215,000. So this is a substantial increase certainly in my view to the spend for our monitoring that is now in the value of this program. All right, so we just talked about gross dollars 34% increase now. This slide is intended to boil that down into a blended trend rate. So one of the interesting nuances when looking at our numbers for this year is we have a change in the payor mix up. We're seeing more growth in the Medicaid programs as we've brought in new communities and Medicaid only arena. And Medicaid happens to have the lowest PNPM so at a pure total dollars standpoint I think on a PNPM basis, our blended rate actually went down. That's actually not the case but it appears that way when we added more Medicaid lives as opposed to more Medicaid lives. This exhibit quiets the payor mix noise. It takes the PNPMs from 17, 18 and 19 and applies the payor mix, the attribution mix by payor that we have in 2019 and applies that backwards so that mix in payor is not affecting the overall PNPM that we're seeing here. When we do that and take our 17, 18 and 19 PNPMs with this standardized payor mix we're seeing a 1.9% blended increase from 2018 to 2019. This is encouraging to us in that we're based on this methodology living within the 3.5% target as set by the all payor model. Out of curiosity, we also took the statewide payor mix and applied our PNPM rates from 2018 and 2019 just to see if that yielded a different result. When we did that, it came up to a 3.0% blended trend rate from 18 to 19 so even if our PNPMs were applied statewide and every life was in a one care program, this model would have us living within our 3.5% trend rate goal. Next section of the budget we'll speak about the other revenues that one care has so the total cost of care targets that really are benchmarks, these other revenues are what help us sustain operations at one care. So this is that next section of the income statement. So really three different buckets of revenue sources. We have our payor partners who contribute. We have the state of Vermont who contributes as well and at the hospitals. The payor partners contribute in the form of PNPMs. It's a variety of contributed life. There's a cash inflows of a one care network that helps us fund our operational management programming and operations in some cases. The state of Vermont supplies funding for the advanced care coordination program, the HF health information technology informatics platform and primary prevention programs. And then lastly, certainly not least, is the hospitals whose participation fees round out the revenue needed by one care to really facilitate these programs and the reforms. So that was the revenue section of the income statement. So this next component will shift into the expense section. And I'm going to start with the health services spending. So before we were projecting what are the total cost of care targets or benchmarks going to be. Now we're trying to project what's the spend going to be. In some cases, those are the same for the Blue Cross and Medicaid and self-funded. We're expecting whatever we negotiate those payors to be our best guess of what the actual spending will be. Medicare's a little bit different. And that's some of the terms of the all-hair model, meaning that the target could be different than our expected spending. But our general approach to calculate the expected spend is really an HSA model, where we take an HSA base year PMPM, and everything is built on the PMPM up. We apply the program trend, or this is the trend that we expect to see this next year, to come up with the 2019 expected HSA PMPM. That is multiplied by attribution, expected attribution, and that's really the HSA total cost of care. We do this collectively for each HSA. It's important to do it this way, because the base PMPM for each HSA is not the same. We have one global target. It might be $250 per member per month for the total Medicaid program. But some HSAs are higher or lower, depending on the risk of their modulation, social determinant factors, the efficiency of the carrier delivery. So we build it from that HSA level up to come to a total cost of care. When doing that, we aggregate up to this slide here, which is the total expected spend. This spend, we break that down to a combined PMPM for each payer program. So this is where the differences in each payer programs of PMPM becomes quite evident. Medicaid is $249 as modeled here. Medicare even $41, so as you add up Medicaid lives, that's why the blended PMPM number would just go down in absence of any payer mixed adjustment. So really, again, a big number in terms of the total spend that we're expecting for our attributed lives on that team. When we think about the spend, at least at the ACM, we start to break it down a little bit into a couple different views and perspectives. Each HSA has a total spend number, but that spend happens in various settings and various proportions. So this next slide here shows, in the dark green, for the locally attributed lives, so the lives attributed to each HSAs, how much of the care is delivered at their home hospital under the fixed payment model, how much is delivered at a different one-care hospital under fixed payments, this could be a referral to a different hospital. The gray section is a non-fixed payment hospital but within our networks, so that could be Copley or Grace Cottage or Dartmouth as a fee-for-service payer. And the last is remaining fee-for-service, that is basically anything else, but it could be a local primary care doctor that's attacking a fee-for-service payment mechanism to be an FUHC. It could be an out-of-state provider that is a fee-for-service basis. As we think about the long-term evolution of this, the no two HSAs are identical. Some have a lot more care that's delivered locally at home, some refer out more and you could be mindful of that as we develop our risk levels going down the stream. This next slide takes a slightly different view and really looks at hospital spending across our network on a PM-PM basis. I think it's an interesting way to start looking at some of the hospital spend numbers, but we're taking the hospital spend and dividing it up by our total one care attribution in public with just a relative amount of hospital care that each of these providers are delivering. I think that this will be interesting when we look at over time with some year-to-year trending to see are there any movements in these PM-PMs and it also is broken down the top section here into two different categories. One is for the hospital care that they deliver for the local lives. The green is for lives that are referred into their hospital from a different attributing community. The bottom graph here is a stack of bars that shows the proportion of spend related to their local lives versus those being referred in are some pretty interesting trends to this. I find that geography often affects us quite a bit for example SVMC is that question from our medical center down in Bennington really doesn't refer to a lot of other Vermont hospitals very often just because of their geography and their capacity down in Bennington. So this naturally segues into the fixed payment model. This is also a part of that section on the income statement of health services spending. The fixed payments represent an important shift away from service. We really start thinking about healthcare delivery in a different way, a captivated way. And the 2019 budget model incorporates fixed payments for the Medicaid and Medicare programs. So the same fixed payment approach that we had in 2018. These fixed payments work a little bit differently. The Medicaid fixed payment is viewed as the true total cost of care. I mean that fixed payment is what we're agreeing to with Medicaid is the actual spend amount for these attribute lives. And it's not said that any reconciliation at your end. Medicare works a little bit differently. They view the fixed payment as really a cash advance and the network earns that back as they do provide care to the patient that have those zero pay, shareable claims, we call them. That really is reconciliation of the year. So if Medicare were to overpay us for the fixed payments, we owe that back to them. They underpay us that they would actually make good on that. That is really a sub component under the program and the full settlement. The settlement is still based on the benchmark that we have for Medicare and the deeper service equivalent of all care underneath it. So we'll take those, the value of zero pay claims plus actual deeper service paid to do the settlements. Just a nuance that I think is important to understand for the fixed payment model. Another important note actually I was going to make really quickly is that the amount that any hospital receives is the payment to cover care for not only their localized but any other referrals in. So that's a component that we look at. How much of the fixed payment was for their local population? How much was referred in from other communities in 2018? We can reconcile that ladder piece to protect events and the market shifts that we might experience. Slide 30 provides a breakdown of the fixed payments in terms of the Medicare Medicaid programs. There's gross dollars just to get a feel for how much money they're actually just flowing through on care to the hospitals. And that breaks it also down by PMPMs and two different methodologies. One is based on total attribution. One is based on for HSA attribution. Really the number that I think is important though is that 25% of the total cost of care is flowing through a fixed payment model, which is a good solid number, but one that we'd like to see increase downstream. Phone's flow is questioned that we received often and really it remains unchanged in 2018, but to make sure that it's understood there's really two add-ons here. At the top we have the payers. This is Medicaid Medicare Blue Cross, which is Vermont, and self-funded plans. And there's a early split that is either pay-to-fee-for-service claims. This is for a non-hospital provider or a non-conference-to-pay-to-perform pilot in the PEN primary care provider, where the provider submits a claim and the payer pays that claim according to their own fee schedule at their own education process. One care never actually touches those dollars. That's the case for QDCs, any non-CPR primary care, and the other continued care providers at whether they're internet work or out-of-the-network. The other way in which funds flow is that the payers pay one care monthly for the fixed payment allocations, the amount that we would agreed upon with the payer to recover the hospital fixed payments and the CPR fixed payments, and then any of the payer investments in population health management. From there, every month, one care makes payments to the participating network providers and pays out according to these three boxes and our payment approaches. For the leftmost box of hospitals and CPRs, it's going to improve their fixed payments. Any other population health management payments that they're eligible to receive care for nation payments, the value-based incentive fund payment, which happens at the conclusion of the plan here, and then any other payments related to reform efforts, such as our specialist reform pilot program that we'll be on now. The other attributing practices received basically all the same with the exception of fixed payments, and then the non-interbuting practices are really zeroing in on the care for nation funds and their participation in that program, the value-based incentive fund, and if they have any involvement in it, if they're specialists, for example, they'll be eligible to receive many funds for that program. So next we're going to get into our population health management spending and because this is really all of our clinical initiatives and the investments we're making in our community we're going to have Senator speak to those. Good afternoon. So I'm going to walk you through the $37 million worth of investments that we're looking to make in our communities over the course of 2019, and describe some of the programs and their expansion as well as some new programs that we're looking to implement. As we look to the programs that really were set in the foundational year with Medicaid in 2017, in 2018 we've been expanding those to our other care programs as well. With our population health management program, we are currently funding $3.25 per member per month into all of our primary care practices based on their attribution. What we've been revising and really updating in this program over the course of the summer months is to clarify the expectations and the accountabilities associated with ongoing receipt of that funding. And so each of our practices over the course of the last three months has gone through an attestation process to make sure that we are all clear on the key criteria for these funds and how they're applied. And you can see in a synopsis level those criteria on the screen. They include making sure that you're using data effectively to evaluate the care that you're providing, having activities in place to address passing care, working on the accuracy of the coding to make sure that we understand the risk profiles of the population panels that you're caring for, as well as maintaining and continuing to advance the team-based care concepts that the blueprint has done so much to put in place over the last decade. In the second investment, we are continuing to expand our complex care coordination program. In 2019, we're anticipating this to be in the range of $9 million. The entirety of that funding comes through one care and is sent out into our network to support our person-centered, community-based approach to care coordination. One of the new things that we're anticipating being able to support in our care coordination program in 2019 is a partnership with the health department and some local parent child centers in a program called DELSE, which is really looking at how we can address social determinants of health and early childhood development to create strength-based programs and really advance care for that potentially vulnerable time in a young child's life. In the third area, we have continued to expand our value-based incentive funds. So this was a pilot program in the Medicaid for communities in 2017 that has advanced into all of our care programs in 2018. And we're anticipating not only continuing that in 2019, but we've also been working through a primary care work group to implement and test people with the course of 2019 some variable models for how the funds would actually be allocated based on what is earned at the level of the ACO. And so we're looking forward to the opportunity to evaluate that and continue to refine it in 2019. Tom spoke just a moment ago about our comprehensive payment reform program. This program was a pilot in 2018 with three independent primary care organizations, and we're very excited that that is expanding on a voluntary basis to nine organizations over the course of 2019. As part of that, they are receiving funding in a new and different way, something that they need to get used to, and they're also investing time and energy and resources and really thinking about how care can be provided in different and new ways. We've been obtaining tremendous feedback from providers and continuing to reform that program as we look toward 2019. In the area of specialists, we are very committed to implementing the pilot program in 2019, and are really looking at two key drivers, the first around improving access to care and the second around quality of care. And so looking for the right levers and opportunities, both from payment and care delivery, to think about how we can better align and support the integration of primary care and specialty care providers to make sure that the patients that are sickest or most vulnerable are able to access specialty care services in a timely manner and return back to their primary care providers as appropriate. In the area of primary prevention, we continue to support the Rise Vermont Initiative, which has been tremendously successful in getting off the ground in 20 communities over the course of 2018. And we're anticipating that that will expand to an additional 14 communities, an eighth, oh, excuse me, a 2019. That program has had a tremendous local success in engaging program coordinators in at least six of the health service areas to be able to identify what the areas of opportunity are and address programs that with small funding and creativity and community engagement really can make a difference in promoting health and wellbeing. In order to support our programs and really make sure that we are able to learn from the local variation as well as the wonderful work that is happening from one end of the state to the other, one care invest funding in regional clinical representatives. These are individuals that provide really peer to peer coaching, they serve as local champions for the work that's happening. They share data and information from one care centrally into their community as well as bring information back about successes and lessons learned. And so all of those regional clinical representatives also serve on our clinical and quality advisory committee providing that bidirectional communication that we're finding to be so effective. One of the brand new areas that I'm particularly excited about for 2019 is an innovation fund. And one care is looking to invest a million dollars in 2019 in local communities to be able to test and evaluate innovative projects that have the potential from day one to be scalable to other communities and statewide. And so this is a program that we anticipate running through our Population Health Strategy Committee which is a quite a diverse group of providers continuum of care representatives and individuals that are very much dedicated to helping make sure that one care is able to advance this mission towards accomplishing the triple aim. These next three programs and investments are really about continuing to bootcamp our health investments from the Medicare program. So regarding the primary patient center medical home payments as well as the community health team payments, we are anticipating and we're actively working with Blueprint staff right now to refresh the Medicare attribution which has been held constant for quite a period of time. And what we're anticipating in that process is that there actually will be an increase in the Blueprint Medicare attribution that we will want to account for. For the SASH payments, we are anticipating a direct contract between one care and SASH to help support the alignment with our overall care model and are looking forward to continuing that partnership. We are anticipating fully funding all of these existing SASH panels as well as continuing the contributions for both ACO and non-ACO participating practices and community health teams. All right, so next we're onto the operating costs which is the last section of the income statement for healthcare. This last shows a summary of the 2018 budget, 2019 budget and the change areas that we're seeing. So we're going from 12 and a half million up to just out of 16 million. Bigger changes happen in the staff area. I'll speak to those in a minute. Contracting services is going up and actually this is back up one step further. One of the reasons we're experiencing some operating cost increases is that Rhizomod is really on-gramming into one care operations. Last year it was viewed as a population health investment and all of their costs were in that PHM category. They're becoming such an integral part of one care that their salaries and a lot of the expenses that they have as an organization are now rolling into our one care operating costs. So that's one of the reasons for the changes. So that's going to be a contributing factor for the salaries, for the contract and services, the investments that they make to build that Rhizomod program and expand it statewide and are included in that contract and services line. We're also seeing increased costs in the categories of actuarial services and legals. We expand our network and have more need to do data analysis and expand hate programs that all require analysis and growth there as well. The other expense category that's showing some increases travel as we have a more statewide network. We're going to have to spend more time on the road. And then the other expenses is growing in large part to do one care work build back. On the staffing changes, really it's kind of a widespread, small incremental growth approach. We did put a lot of time and energy into looking at the staffing model. We had reacting to the needs of the network and making sure we had the right people in the right positions to meet the needs of our network. So there's really 7.1 FTs that are related to one care operations. The bottom section here is four of those Rhizomod positions that are now on track and into one care. And then there are two positions that are in the budget to do specific work on a lot of the opioid use disorder projects. All right, reserves. And this happens to be the answer to the very first question we were asked by Mullen, which is what was the difference between those two numbers that are perceived. The answer is the reserve calculation. So the 2019 budget model has a $2.8 million operating gain. This is the means by which one care can develop reserves. As a reminder, there's a budget over in the 2018 program a year to have $2.2 million of reserve built by the end of this year. We have intended in this budget model of add $2.8 to that to have a $5 million reserve. These reserves are becoming an important component for one care. It's taking some thought to get to this point, but one of the finding results of our network development strategy this year is that the downside risk is a big deal for some of the smaller hospitals and their balance sheets. Having some reserves that one care can be a useful strategy to help for anymore. And especially when we start getting into the Medicare program. So that's one reason to have some resources that one care makes sense for our network development. One of the concerns raised last year was the issue of default risk. If a hospital were just to not pay a downside risk payment, how would one care protect itself and its solvency? And the answer to that is to having some reasonable reserves. The other is just regular cash flow for a growing business. And the amount of dollars that one care are growing is our network growth, and our programs grow. And having some, having a balance sheet to rely upon to cover timing issues with a payments account for the payers or with a network is an important aspect. And the last point we made here is that we would like to see this scale proportionately with our overall network growth. The one other note I'll add is that any reserves that one care builds or intends to build should be considered in context of other payer program requirements. Medicare, for example, has a reserve requirement that comes along with being in the next generation over on ACO initiative. That was a substantial amount of money. It was about $4.2 million and had to be secured to be in program environments of Medicare. So really, any reserve requests, we ask be considered in context of other reserve requirements that may be endless. All right, next I wanna talk about what this really means with the network and their commitment to this accountable care, value-based care approach. So really one care, that's anything most of you know is a network of providers and we're all coming together to further the components of the triple aim. This really is a big task that takes both clinical and financial reforms working together to achieve these results. I think that if we just were to do financial reform and have no clinical investment, we probably wouldn't achieve great results. And in many cases, the clinical reforms can't take place without changes to the financial incentives that are put in place in the financial model. So it's a very connected mob. To do this, to pull this off, takes really two things. One is exactly downside risks, which is the financial reform that flips the incentive structure so that a well-population doesn't damage the delivery system. And it takes investment in our programs and those investments come from other places when the payers contribute some other interest streams, but the hospitals are also major players in investing in the models so that we can sustain and do well in the financial paradigm. So with that in mind, a little bit on risk and what's included in the budget model. This is bearing that risk is really a requirement of these accountable care models and as in just like in 2018, each hospital will be supplied a maximum risk limit calculation that takes their HSA spend, spend for their HSA lives and applies the program risk terms, the corridor and the share that may be in place to their HSA spend to come up with a maximum risk limit. Technically, all of these programs settle at the ACO level, so one HSA could drive the entire risk portal to the ACO. We don't want that to happen because that could jeopardize the solvency of any one HSA. So we apply these maximum risk limits and the rules about how any risk or reward above that limit is handled in the network as a real protection for all of the HSAs and the hospitals bearing the risk. What we have in here for risk corridor terms and all these are subject to negotiation or in some cases decision by the one care board, Medicare will maintain the 5% of the risk corridor but transitioning from an 80% share to a 100% share, this decision is supported by the fact that we anticipate having some shared savings because of the conservatism in the 2018 target for the blueprint. So essentially if we were to hit our actual actual claims target right ahead in 2018, we're gonna owe back 20% of the conservatism that was given for blueprint. After the results over experience and thus far, we think it is right to do away with the 80% sharing and make sure that we can carry forward as much shared savings as we can earn into the future years. Medicaid moving from a 3% risk corridor to a 4% risk corridor. This is consistent with the program evolution of Medicaid and taking measured steps to move it forward and increase the accountability under the model. Blue Cross maintaining the same risk models with a 6% corridor and 50% sharing of the corridor. And then self-funded, this is very premature but we're exploring some downside risk elements of the program which would have a 6% corridor but a 30% share that 30% is meant to ensure that the lives of the tribute would qualify for scale targets under all of our model. So this next slide builds upon everything discussed thus far, the estimate attribution, the estimated total cost of care, the model risk terms and boils it down into estimated hospital risk. It's a big number, it was $34.8 million of downside risk or upside potential for these programs. Ultimately, the actual upside and downside risk is dependent on final attribution that we receive, actual total cost of care targets that we negotiate and finalize with the payers. This is meant to represent our best estimate of all of that and help hospitals make decisions and their boards make decisions about whether or not to participate and whether or not a year in which they have to pay up to the maximum risk limit would be harmful to their organization. One other note on here, there are some risk mitigation solutions that One Care has developed. There's a risk mitigation model for the Medicare program and there's risk mitigation arrangements for the hospitals that are not factored into these numbers. These are just the gross risk numbers and essentially the check that One Care would have to write back to these payers if we completely maxed out our downside. All right, so next we have our hospital participation costs. These are really the amount here, this $29 million is the amount that we need from the hospitals to fill the One Care budget model here and we collect those either through fixed payment induction when we're able to Medicaid the Medicare programs or quarterly invoice to the hospitals. I really want to break this number down into a couple of different components. We have a gross production amount of $29 million, that's the amount that the hospitals are paying in a monthly, quarterly install and still One Care. That really funds two different components. One is the investment and popular general management programs that comes right back to the hospitals. So they're contributing to One Care programs but they're also recipients of those funds. So one could view the expected Ph.M.C.s column to share that $14 million as really a cash flow function. We're withholding the dollars at One Care so that we can operate the programs that are ultimately paid right back to the hospital network. The amount remaining is really the net cost to the hospitals of One Care. And this would be the amount that would essentially go away if they didn't participate at all. So that's $14.6 million. That can be broken out into really three categories here. One is community investments. So these are investments where the hospitals are paying into health fund One Care initiatives and payments are being made to other community providers that are into agencies, independent primary care, through HCs, et cetera, and really investing in population health for the other community entities that are in our network. We also have that contribution to reserves number here. There's the $2.8 million in the records before. And then the last is contribution to One Care operations. The $7.8 million is really the amount that One Care needs after factoring in all of the revenue streams that we could use to help fund regular operating costs. So now that you've walked me through a couple of highlights related to our clinical and quality outcomes. We have spent from this time in the last couple of years talking to providers across our network as well as working with the Greenland Care Board staff and the health care advocates and really looking at the opportunities to align quality measures under the all-payer model. The latest work that collaboratively in that is really been around aligning the Medicare quality measures that will go into effect for 2019. And the accomplishment there collectively is that over the course of the last two years, we've really been able to take a disparate set of more than 40 quality measures, many measures which did not align across one program and bring them into alignment. And so you'll see here a set of 15 quality measures, usually about 13 measures for any one payer program. The intense focus of these measures and the alignment under the all-payer model really needs a couple of key goals for us. It looks at effectively being able to reduce the administrative burden of primary care from having to develop systems and processes for oftentimes measures that had slightly different definitions and became very frustrating to try and figure out how best to track. But also, it's really looking at measures that are clinically important. They're important to the overall health and well-being of our monitors. And our providers feel very strongly that these represent a diverse set of measures that really allow them to set targets and goals to strive forward towards. Looking at our 2017 quality measure performance, results became available recently. In our Medicaid program, again, of the Long Island communities, we achieved an 85% quality score overall. This was using up a brand new set of measures for us. And one of the key determinations related to our ability to reinvest in quality is that our population health strategy committee and our board of managers approved and worked collaboratively with DEVA on a reinvestment strategy for the component of the value-based incentive fund that was not successfully earned. So this was the 15% that we did not achieve by the quality score that we obtained. And so the plan that we have in place now and we'll be operationalizing over the next few weeks is to be able to send those funds out into the local communities in those four health service areas through the function of their community collaborative, also known as their accountable community for health, with some guidelines from one here about areas of opportunity that align with gas and care. And then for us to work with them around how to design specific programs and projects to address those gas and care over the course of the next year. Within our food cross-lube shield program in 2017, this was a shared savings program. And you can see that we were able to achieve 73% of our quality score and really maintain the overall quality across most measures. For Medicare, we achieved an 88% quality score. And one of the things that really was changing for us in that shared savings program year is that six different quality measures that had done reporting measures became payment measures. And that did have an impact on our overall quality score as well as the quality scores for other ACOs around the country. And so I just gave this next slide. This is an opportunity for us to look at under the Medicare shared savings program, how does one care compare to all of the other ACOs on two dimensions? Across the x-axis, we're looking at the cost per beneficiary per year and on the y-axis, we're looking at that overall quality score. And if your eyes can search it out in that top left quadrant, you'll see a green dot. And that represents one care's performance relative to all of the other ACOs. We pay tremendous attention to this. And this for us is the high value quadrant. We always want to see that we're able to function and support Vermont and healthcare reform by really leveraging high quality care and controlling that cost growth. This is just a quick example of some of the types of activities that when we take a longitudinal view of our quality measures that we're able to see some growth and some impact. And so this is a measure around adolescent wealth care, looking in the left-hand chart at the shield qualified health plan program and on the right the Medicaid program. The very colored lines are really showing you the benchmarks by year and the bars are showing what our actual quality performance is. And so you can see we're making incremental and steady progress, the most dramatic of which is really that in the last year in the Medicaid program as we were able to really advance towards that 75th percentile. It's interesting to note that this quality measure nationally has stagnated for a long time. It's a very hard measure to move. I often spend quite a bit of time talking about our care coordination program. And so rather than walk you through the fundamentals of the model, I thought what I would take a couple of minutes to do is highlight some of the early results and then share with you a case study, a real-life example of the way that care is changing in our communities. So in this chart, what we're really displaying here is that for all of our care programs, so regardless of which program a participant is in, if they were successfully engaged in our care coordination program for between one and six months, we're looking here at the utilization of emergency room visits. And what we're seeing is that with the beginning of the 2018 calendar year and the transition to these risk-based programs that we're actually seeing a trend showing some decline in those emergency room visits. This is still a early signal. We have many other metrics that we're paying attention to and we'd be happy to describe. But these are the types of information that we're sharing across our communities as we start to look at the impact of this community-based care coordination program. So in this case study I'd like to share with you, we're looking at a Medicaid member who was determined through our risk stratification program to be at very high risk. She's in her late fifties. She has extraordinary medical complexity. And to the surface of this case study, I'm going to call her Sally. Sally over the course of the last 12 months had a risk score of about 14, which is extraordinarily high when you look at our population. Her spending was above $120,000 in the last year. She was admitted to the hospital seven times. Four of those times the cause of her re-admission was related to the initial diagnosis that she had had and she visited the emergency room six times. Sally has diabetes. She has COPD. She has congestive heart failure. She's obese. In total we've captured 28 different health conditions that would Sally at increased risk. Unfortunately Sally's pattern was to spend one week at home followed by roughly three weeks in the hospital and that pattern was repeating itself over and over again. In August, Sally was identified as someone who could potentially benefit from enhanced care coordination services. She was outreached to from a primary care practice and selected a nurse in that practice to serve as her lead care coordinator. Sally described herself as depressed, fearful, exhausted by her many admissions and all of the transfers, the documentation, the details that she had to track. She was able to articulate that her goal primarily was to stay at home but that the complexity of her illnesses made this particularly challenging and it was recognized that without strong coordination across a number of service providers that that was unlikely to happen. Because of Sally's underlying conditions as she was discharged in that last visit in August, she could not be admitted to a skilled facility because they didn't have the services available to supply the advanced means she had for IV medication. So her hospital case management team worked to stabilize Sally. They actually concerted a line to help her be able to get her medications and they stroked to really figure out how they could get home health to support her. The initial plan was that she could be at home but she would have to travel to the hospital every day for her IV medications and in order to do that someone would need to help arrange for specialty band transportation back and forth each day and for a whole variety of reasons that was a process that was likely to not result in the type of care that Sally really needed in order to be able to break the cycle of hospitalizations. So the local and the referral hospitals collaborated. They worked together through pharmacy and supply chain. They identified all of the equipment and the surgical supplies that Sally needed. Her lead care coordinator worked across all of those systems, addressed her needs for specific prescriptions, identified barriers related to her out-of-pocket expenses and helped support her and her to be able to obtain those medications. The care team identified medication complexity as a barrier and arranged for bubble packs so somebody could actually count and aggregate medications so that there could be a process and a standardization about which medications what time to take them, how to take them. That care team held multiple care conferences both by home and excuse me by phone and in the patient's home. It involved home health, the choices for care program, her nurse care coordinators, her neighbors. I diverted educator, her husband and pharmacy technicians. The lead care coordinator organized the team to care for the husband. Also a patient in that practice but one who's not attributed to the ACO. The husband was significantly older than Sally and was experiencing other social and economic challenges and was asking for help. The lead care coordinator identified existing social supports, many from her local neighborhood, as well as arranged for a plan for those neighbors to come in and support Sally and her husband in cooking, with caregiving, checking on them to make sure that they were okay on a daily basis. All together providing for a more stable home and emotional environment. The early signs indicate a significant reduction in Sally's utilization. She's now been at home for 11 weeks. She has not had any admissions or emergency room visits. She's successfully managing her complexity. She's weighing herself. She's managing her conditions. She's actually successfully completed several of the goals in her care plan and has now set new goals for herself. So I share this case study with you as an example of the type of transformative care that born care is really trying to support and facilitate as we're aligning the care delivery system at the local level as we're bringing together talented professionals across many organizations and working to break down the barriers, often systemic barriers, providing optimal care. Before I finish up, I'd like to just touch briefly on our patient benefit and case and waivers. You've heard me speak about these a bit before, but two important notes that I wanted to bring forward today is that as we spend time meeting with both our current network participants as well as those that were considering joining us over the course of the summer for 2019, one of the surprising things that I learned was that it was actually these patient benefit enhancement waivers that were a key driver in the decision making at the local level about the potential impact and the way that it could be felt on a person level basis for transforming care. As we've implemented these waivers, I just was getting an update today for the skilled nursing facility waiver that allows an individual on Medicare to waive the three overnight stay before being able to be transferred to a skilled nursing facility that was first piloted in the Millbury Health Service area and they've now successfully admitted 18 patients through that waiver. It's spread into the St. Alvin's Health Service area. They've had their first several patients now admitted through that waiver. It's active as well down in Brattleboro, the very first patient. We've been continuing to train new communities and I think one of the biggest challenges that we're facing with this waiver is not whether patients are interested, it's not whether this results in better care. It's about making sure that we have the skilled nursing facilities that have a quality level that allows us to be able to bring them into the network and utilize this waiver and so really helping to support that program and moving forward will be a next task for us. In terms of the two other waivers, they are in early stages of implementation. We are underway with SASH in a pilot program for the telehealth waiver for residents in some of their settings and connections to their primary care providers. And then for the post-acute home discharge waiver, we're hoping to implement the first pilot program in November. We have been challenged by some of the legal and contractual requirements that are necessary to be able to fully deploy this waiver in the way that works for our network. In other ACOs around the country, it's tended to be done in a centralized fashion, maybe through a clinically integrated network, but we're really looking to build that partnership more strongly between our providers and our home health agencies and so just working through the details of how to make that happen has taken us a little longer than we anticipated. Before I end, I wanted to touch briefly on our Population Health Management Platform. This is really the sophisticated set of tools that we bring together and brand at Workbench One. Workbench One allows us to integrate data from multiple sources. We bring together our claims data, our clinical data feeds from our electronic medical records and our health information exchange. We bring in event notification data, something new to us in 2018, as well as our care management data. And all of this data come together and are accessed by an extraordinarily talented team of analysts and programmers who take that data, really the raw output, and are able to bring it together, turning that data into information that's actionable for both our monitoring as well as for driving change and improvement, whether that be at a statewide system level or at a local care delivery level. We also use this analytics platform to support our payer reporting and our regulatory requirements. We feed data to our clinical governance committees, as well as specific local and statewide change efforts. So that might be a learning collaborative at a local level, a statewide one that we are offering, such as our diabetes and pre-diabetes management learning collaborative. And we support local efforts be that at the individual site level or across an accountable community for health. All right, thank you, Thomas, Sarah. Good job. All right, so as we conclude our informal presentation, just a couple thoughts to put this year's budget in context for where this is going in all of your model. I think we're, you know, we've started something really good here in Toronto. People are really interested nationally to see how this is gonna work. And, you know, we're all working really hard to make the model right. But thoughts on insurance success for the rest of the model after this year, I just wanted to take a couple of minutes. I would encourage us to focus on affordability as having a true north, which is the all fair model for a rate of 3.5%. And, you know, the way you gotta think about this is on a statewide level having a model for what you think the different categories are gonna grow at and then understanding what is one care's unique payer mix and is the population even within a payer that we attribute higher or lower risk than, you know, the statewide average. That really gets complex, but it's really gonna be essential for us to agree on how we measure that rate and what one care subset of the state accountability that we have.  I know we all worry about affordability and a lot of times that ends up being just focused on the commercial and sugar. But this is an all fair model and we do have a definition of affordability at the 3.5% growth rate level. We believe in our best ability to calculate it that if the entire state was in one year, we would be proposing a growth rate from 2018 to 2019 of 3.0%. So it does even leave a little room in margin for air for the non-attributed lives and for final models and targets. You know, but I really urge you to bring in your regulatory models or the ACO under all your model to use that 3.5% to ensure as your true North and regulatory guidance framework. A lot of the regulatory oversight levels, I mean, this is what we've talked about together for years, which is, you know, you as a regulatory body are unique nationally in having a dial for hospital budgets, the largest chunk of spend in a healthcare delivery system and under the total cost of care. You have traditional insurance department role in fully insured rate regulation under the same hat. And then we've had the middle layer of a kind of a care organization, risk very high, taking risks from payers and then paying providers and delegating that accountability within our spending pattern. You know, one of the things that I think through the first time this year that there's gonna be some real conversations in terms of if we have something in our budget that we think is consistent with the 3.5% growth rate and our expectations from the payers. And we negotiate that. But yet the payers or the state budget for Medicaid can't align with our 3.5% growth rate or what our PM can, we might say we think is a fair target for a commercial program if that money isn't there or it's misaligned somehow. You know, how we close that gap is gonna be important and you gotta remember that as an ACO, we don't have reserves. We don't have an adverse risk adjuster to pay us next year if we end up with a riskier population than we set course for. It's a voluntary model, meaning that I've got to bring before we sign contracts to a board of providers that are at risk of a proposal and our best projection on whether we think we're gonna do well on the model and the higher probability that we bring them a target that we think might be what we call underwater for a month one meaning we really, really are not going to have a chance at an early shared savings. We almost certainly entered shared losses. That's the real thing that we need to protect against and really the one thing that you need to work with us on if you really do care for the all-hear model and its sustainability and success. Committed, flexible, responsive payer partners, certainly trying to get this into the vision of all-hear model that these are aligned models in terms of levels of risk and the ways that we can pay providers differently underneath the population targets and the fact that there are expenses in implementing reform that were originally intended to be under a lot of funding from the delivery system reform program that hasn't really fully materialized. We need to pay our partners really, really what we're doing or willing to invest in it with us even further, especially as we scale this thing. And then finally, especially for hospitals, I gave you this information last year. Hospitals are really stepping forward in this model. We're gonna have 12 of the 14 in Vermont and the other two were very interested but just for a variety of reasons, just weren't the financial position to assume the risk. But we have 12 hospitals in this model. In Vermont, we still have the original founding partner of one caregiver with Hitchcock as a very dedicated partner in this thing. Between funding, about half of the transformation out of hospital dollars, accepting the payment reform for what happens in their home four walls while taking a fixed payment monthly to cover any services that they have to provide to our treated lives. In addition, taking the total cost of care risk, which includes for the first time against the hospital balance sheet over this program in Vermont, hospitals are taking accountability for claims spending for things that could happen a thousand miles away. And that's a brand new risk on hospital balance sheets that never existed before. It's one thing to say, we're flipping the axis for your services that we are to reward high value in your hospital and now we're going to reward high value in your hospital. But on top of that, taking that extra risk on the total cost of care that's embedded in ACO models is a big deal. And especially as we scale the model, if you really believe that we're gonna keep making progress on scale targets and need to make progress on scale targets, I think the hospitals are about tapped out under the existing models in what their balance sheets can bear. The $34 million of total risk that Tom talked about is getting to be such a substantial number that from here in 2020, if we're successful in additional scale, we have to have a really serious conversation in terms of if we wanna build additional reserves at one care so that we can limit the $34 million maybe in a flat year-to-year basis. Do you want to allow hospitals that are taking that risk to have extra hospital budget accommodations to build reserves so that I can give them more than $34 million worth of risk and not have it be a safe risk and funded risk? That's gonna be the really most important discussion we're gonna have as we get into the second half in year three of this all-payer model.  And at this point, I think we're gonna have a formal presentation that we'll end with a question here. So thank you very much, it was a great presentation. I'll start off with some of the questions. If you go back to the slides, the network participation. So we know that it's a joint collaborative with Dartmouth and UDL. It appears that if we start with this course, that they can't participate on the Medicare population of the borders because they're participating in the next-gen project in New Hampshire and that federal rules include them for participating in Vermont. I'm wondering if you've quantified the number of Medicare lives from Vermont that comes up to and if there's any plan to try to figure out some way around the federal regulation? Yeah, I don't know the answer to how many Vermont Medicare beneficiaries receive their primary care and an attributed relationship with New Hampshire-based Dartmouth-Ditchcock providers. I do not know the answer to that question. And we have not done that yet. I'm just concerned about that, knowing that we have that benchmark 90% Medicare participation by 2022. And so I raise that question. On the slide that has initial attribution estimates, under the self-fund, how many different insurance companies are we talking about? Yeah, so that really is projecting a four-hospital cohort doing a model similar to that of two-sided risk, but similar to what we're doing this year as a pilot of the University of Vermont Medical Center. And so really, we're anticipating and budgeting three additional hospitals joining that cohort under a single program as a bit of a pilot and an innovation model with multiple payers with direct contracts to one care, on top of whatever carrier they otherwise would have. In addition to the self-funded, we're currently working on one contract with a carrier that does have quite a few lives in Vermont. We're working on a model that does qualify for scale targets in a way that would allow them to bring all attributed lives for all their self-funded clients in Vermont into a single performance pool. For us, we are currently under a non-disclosure agreement as we work through the negotiations, so I have not really given you more details of that program than I just did. I'm also feeling a little bit of displeasure on the QHP category, knowing that NDP has increased their lives in the QHP program, but it doesn't appear that they're a participant in this year, so I've just stated some dissatisfaction there, that's all. On the slide for fixed payments, under the Medicaid remember for Vermont total attribution column, is there an equation that we could have so that we could figure out how these numbers have been achieved? So the fixed payment amounts are something that we model, and we really, this is probably the one example we'll remodel from the gross number down to the PMPM. We're looking at spend within, for the attributed lives, I mean, where it's occurring across our network, we have these grids that we produce that show determining what you say and where the lives you see that care, so that can be at their local hospital, another hospital in numbering of fixed payment all the way out to the service categories. We use those historical spending distributions to estimate how much care will be delivered by one of these hospitals in the next year. These are good models when we get revised data for the actual community population and incorporate that with the experience that we're seeing this current year, and that will ultimately determine how much each of the hospitals receiving the fixed payment, but it's really our model of best estimate of how much care these hospitals will provide to any one care life in the play. Sir, you did a great analysis with selling. Yes. What I was trying to think about, you know that hospitals have done the equivalent of a look at frequent flyers for a number of years, huddling up once a week and trying to discuss those most frequent users of the services and trying to figure out a plan to get them in a better place. What is different about your care coordination that is an improvement over what had been occurring in the past? I think there are a couple of factors. The first is certainly scale. So when I had spent the last couple years traveling and talking in local communities about some of those collaborative efforts to address those frequent flyers, it's often five or 10 or maybe 20 individuals that they're able to prioritize. And so what we're really trying to do is we take this holistic view and make sure that we have a care coordination program that is aligned across all of our payers is to add a capacity to make sure that we're talking about hundreds if not thousands of patients in local communities and making sure that we're proactively assessing their needs. So I think that's one component. Another is that I see the work that we're doing as really expanding that care team. So there's been tremendous successful work in looking at team-based care models in primary care as an example. And they're highly effective. But as I travel around the state, I don't always see that they are thinking more broadly or more inclusively about all of the continuum of care partners but also human service agency partners and professionals who are actively supporting the needs of individuals. And so it's really deep transformative system level work that needs to happen. It's much more complicated than we might have initially anticipated. And it's really driven by workflow development, trying new things out, figuring out what works for one individual and seeing whether that can work for more and doing that at scale. It's exciting. Hopefully, this is what part of what better well comes in hospital based on... Yeah, and we were adding more tools to the toolbox, right? We really are just trying to empower communities and those providers and even the hospitals as anchor providers in those communities to do what they wanted to do and not really had all the tools in the toolbox but bring some of our waivers that Sarah talked about, our relationships that we've built in the community clouders with the community based organizations and home health and other programs and tools to make sure that we have a game plan for all of these patients that makes sense and has a higher chance of working. If I could just add to that, I did bring one new statistic along with me which is that over the last nine months as we think separately from our software implementation around care navigator we really look at the tools, the knowledge, the language, the skills around care coordination. We've successfully trained 586 individuals in either the core competencies or in advanced skills and that to me really speaks to our ability to reach to all corners of the state regardless of direct ACO participation or not but to get communities ready to be able to join our network and to have those tools and the facility and the knowledge around how to support true transformation. One of the complaints that we hear occasionally is that the approach to care coordination by one care is a decentralized approach and some national research has shown that a centralized approach works better. And yet when you think about the history of Vermont with the movement for health and the successes that were reached on a decentralized approach but frankly I don't know how you'd ever get participation without having a decentralized approach. I just want to know if somebody could address the controversy of the centralized versus decentralized. I spent a lot of time thinking about that because certainly as I travel and talk with other ACO partners around the country they do have centralized models. At most they might have embedded models of ACO staff in certain locations. So what Vermont is doing is unique but Vermont is often unique and in the forefront and I think you're absolutely right. We do well in local models that really take into account the local conditions, the understanding those partnerships. And so the challenge that I see is finding a line between making sure that we have standard measures that we have the data, the accountability, the tools to be able to support the education and knowledge, the communication but that we provide the flexibility for the local decision making, for the local workflows or how communities collaborate together. And it is challenging. It takes time, it takes honesty, it tough conversations and a lot of transparency. So people being willing to share not only within their community but across communities what's working and what's not. I do feel very confident that we're on the right path and that we'll see tremendous scale grow over the course of 2019. So you just mentioned the word data and that brings up a public comment that we received and I felt the best way since you were gonna be here today is just bring it up directly with you so that we can get any answer. But public comment is from a person in Johnson and it basically says, could one care Vermont please comment on this decision to eliminate the director of analytics role from the organizational chart. Also the decision to add the manager analytics role to the quality manager who has no formal analytics education and they go on to say with ACLs fundamentally being an analytic revolution. How can there be a qualified, how could there not be a qualified senior leadership overseeing the analytics at the heart of the one care's request for nearly one million. Yeah, and so some of the publicly submitted but our informatics analytics infrastructure that had scratchers. Not really sure what the source of information is but basically our informatics isn't existing for informatics sake it's to transform care and it's to transform the payment model from value to volume. So in that it really needs to support those two major functions we did decide to put a little bit more accountability for the informatics under finance and under Sarah's leadership and clinical quality improvement. The individual that's actually overseeing that team on a day to day basis does also have some responsibility for our quality measurement team which is in high alignment and included in what we do in informatics standpoint but also had substantial experience in a military role in large data informatics. So highly qualified when we did have some turnover among our leadership over the informatics team we oversaw the team on an interim basis under Sarah's interim directorship and it worked so well that we decided to make that our permanent model. So to the degree that we wanna be transparent and have dialogues in our decisions around the best way to oversee our functions I think should be within our purview to make those decisions. Okay. My last question before I turn it over to the next board member. It looks like you're looking at 2.8 million to reserve some additional 2.2. 2.8 million looks like it's from your margin. In a Tuesday scenario where one care ceases to do business. What would happen with those dollars? That's a great question. And we're actually working through that collectively with our founders and our board. It's a really good question that needs to be answered actually before the 2018 year ends up. It's one that has an intersection between our operating agreement with the founders which would have been the governing documents that guide one care operations and there's some accounting treatment and tax treatment considerations. I think it's safe to say without speaking on behalf of our founders and the board that we were looking for a model that is reasonable and fair and reflects the source of the reserves and in the event of a company liquidation who treat those in a manner that's fair and read upon by the participants on the board. Who would like to go next? Everybody's hand was up so I'll start with Jess and work my way down. I'll take care of it. I thought you were looking for volunteers but we had a lot of volunteers. Okay. So first of all, thank you for the presentation and Todd I really appreciate your opening remarks about this is the beginning of a process and the extent that my comments that follow are I understand that you are working. This is the start of a long, hopefully long, model that is gonna require some more than the foundational building. So, but when I think about budgets, I think of them as forward-looking documents based on strategies to achieve some goals and the goals I think about here are scale goals, payment reform goals and delivery reform goals. All that's achieved will down the cost for an improved quality of care for the monitor. So when I think about first of all scale goals I was struck a little bit by, there's a commentary in here about how one care has not set numerical goals for provider participation and attributive lives by HSA and hasn't done an assessment of penetration rate by HSA. So I'm wondering if you could speak a little bit to that why there are no goals on the scale in particular by HSA and penetration rates and provider goals. It seems like we should have some goals to try to follow. Yeah, and I'm not sure I disagree with that, but you're right, we haven't really thought about that and as you know, with your long service here on the board, this is meant to be a voluntary model. So we spend most of our time and energy trying to make it look like a great idea to say yes to providers and payers that participate in the model as our approach to scale and hope for the best. We believe at one care in the scale targets that we're really designed to say the greatest transformation is gonna come when a majority of patients in Vermont and percentage of revenue, if you wanna think about that for providers or percentage of panels of your primary care doc are in an aligned common incentive model. So I really do believe, based on my entire career plus this all-care model that the scale targets trying to get to that tipping point of more than half and hopefully toward that 70% made a lot of sense. These first couple of years it was, could we attract enough and see where we are? I think that this will be the cycle into year three where we're gonna get more serious in terms of where can we make additional large strides toward the scale targets. One of the big ones is gonna be, we need to get people into the Medicare program. So the Medicare risks scare some of the risk-carrying hospitals. The high spend for beneficiary, the number of Medicare beneficiaries we got in Vermont growing with the aging of the population. And the risk for or receiving that minimum 5% on Medicare makes the maximum risk number for being in the Medicare program a scary number even when we actually are really convinced now that you got a really good chance of beating the targets. And so that's one is we sort of need to crack how do we get hospitals in for all programs including Medicare and that's one of those relationships to the hospital budgets. So I think we're gonna turn our attention to be much more proactive in terms of what are the large levers, how many lives would they bring in a more planful way? So I appreciate the input and the question. Okay, and just let me ask a quick question. Actually you answered my Medicare question. I was gonna ask you about why Medicare is so scary. I think you sort of answered that in that. But actually your slides, one of your slides about participating providers is you actually need to decrease how long independence is slightly decreasing on primary care one practice but then five specialty practices. And I'm just wondering, is there anything that we should learn, worry, be concerned about? Everything else is moving in a positive direction except for the independence. I'm just wondering if there's something you can share about that. Yeah, I think that the independent primary care was one practice that didn't renew. The specialist one is one to jump out the page to me as well. I think it's reflective of the initial programming that one care has developed hasn't really zeroed in on specialists and that's why it's a core component of our 2019 model is to start integrating them, especially independence into our reforms, into our health system and more clearly show them the value that the ACO adds to them and offers them. So I think there's a number of practices that I'm not seeing so much out of one care yet and I'm thankful for the 25 of us stuck around and think that we can continue to grow this with more target programming. Yeah, I think that the one practice that did exit on independent primary care was the pediatric practice and with our focus starting on high-risk patients' care coordination, the PDI population isn't the multi-pollicronically ill population and probably it's almost a nine in the collective. There's not much in it for them currently. And I think it's the same for independent specialists as part of the reason why we're adding a specialist physician payment reform model for next year. It is to start to engage them more in the population health management. They could be really important in the rising risk while we want to sharpen our approaches on. I think you'll see the independent specialists go for a grow as they see this pilot that we're gonna implement in the next year's project. So the second bucket of goals for a positive and payment reform and I think, if I understand it correctly, about 25% of the total cost of care spent right now is in fixed payment. The remainder, from what I understand, is still in deeper service. Is that right? Do you have goals regarding that moving more, what are your goals for the next couple of years in moving money out of deeper services towards fixed payment? Well, and we do want to work with our commercial insurers to sell them on the attractiveness and help them be able to operationalize the fixed payment model for the hospitals. We really do believe that provides the sharpest, clear incentive for the hospitals for value over volume. So one reason it's at 25% is that we don't have any commercial payers that participate in the fixed payment model program. We can simulate it behind the scenes against a retroactive settlement against deeper service, but that is slow after the fact and not a sharp of an incentive. So we do have a goal to get more of the 3D population in the fixed payment model. That's my follow-up question actually related to that. So I was struck a little bit also by the comment here, he was on page 15 of scale strategy three, which said, currently we're experiencing limits of the commercial payers' willingness to align the business models with the LHAC model and the program brand that is in the performance and population health management approach is set forth under the Medicare and Medicaid Next Gen program. I am wondering if you can speak a little bit to swim the obstacles to getting more commercial payments into fixed payments, getting on board. He said that you can speak to it. Here, do you want to take the opportunity to meet your oyster here? So I've done a lot of work on the commercial side of things, as I know you know. And we're really running into, you know, you talked about disappointment and MVP, I've done that for a second. But, you know, they come from New York, they don't have a huge population here. They have a different model in that state, changing, they're not able to implement fixed perspective payment, you know, doing something for the small group of members that they have here is really difficult for them. And so while we've had extensive conversations, we're so far apart on the models that it just doesn't make sense at this point in time to contract. But it's anything from believing in the model, understanding the model, sharing risk, sharing claims payment data, you know, that's something that we're getting significant resistance on the new payers we've talked to. Quality metrics, one of the other commercial payers we've talked to, they have contracts already in place with employers that have very specific quality metrics and incentives for them. In order for them to share those dollars with us, we have to align to their model, not they align to our model. And so I think it's going to be, well, we've had a great conversation and I think we've done a lot of educating for new payers coming into the market or entering into the out there model. I'm hopeful that maybe in another year we can really get there with more conversation. We didn't include a lot of detail or numbers in our budget because we're not sure we're going to get there for some of the payers which we might need. But we're hopeful for 20 points. And that's a great answer, which allows me to make a point of, from a provider standpoint, we want to align population models, right? So we can think of all the patients we touch and to send their way based on their needs and what we need to do to keep them healthy. From a payer perspective, they want all their provider network accounts to follow a similar model. They like to use their value-based purchasing as a differentiator in the marketplace. And both positions can be right. And so you sort of end up trying to find something that meets in the middle. And we've got at least one payer we've traditionally contracted with that we think has been on the side of it works, right? MVP didn't quite get to that middle layer and sort of was a little bit too much toward a model that didn't make sense for us. So this is gonna be a bit of an ongoing evolution on this model for how it's not the only state struggling with this issue as they try to do all payer models or multi-paramount models for accountable providers. I'm glad to do this often. And it's believed to that that a Dartmouth-Ditchcock is not in an experiment. So is there any form of Medicaid or for commercials? How does the partnership with Dartmouth-Ditchcock and the movement towards getting them on to explain it like the other hospitals? Yeah, it's there. Yeah, I mean, Vermont with its really focused on local hospital autonomy, leadership and accountability. The Vermont culture really meant itself to local communities want to be responsible for the total cost of care for their local community members wherever they get their care. And so really we had a long discussion in terms of what does that mean when they end up at Dartmouth-Ditchcock and both the local hospitals and Dartmouth-Ditchcock both thought that it would be better to leave that spending accountability at the local community because we did believe there was a danger that local communities might start sending more types of care than needed the level of care at Dartmouth-Ditchcock Tertiary Center could provide if they didn't have that go against their own accountability. So I know it seems weird that Dartmouth-Ditchcock is still largely a fee for service provider for our population, but no organization nationally has had a longer dedication to population health management and trying to take these accountable models and make them successful. So they're not just another fee for service member in the network, they're a highly collaborative one at the table working with us, looking at data to try to understand that. So, you know, it's not a worry for me. Now Dartmouth-Ditchcock, when they do attribute lives in the programs they participate in, take the risk like any other hospital. But from our payment model perspective, even within the state of Vermont, University of Vermont Health Network, even though they get paid respect in the payment model, when they serve people from another community, that goes on that other community's dime and we settle that up behind the scenes against those fixed payments. So they're really no different than University of Vermont medical center is when people come from other communities they are under our risk-earing model. I have one other nuts and bolts thing to add on this. And that was a nuts and bolts amount. I'll take that out. So with our fixed payment market installation model, we keep the home hospitals that are local life certificates paying that concept. For the referrals in and out, that is subject to reconciliation and Dartmouth does so much care when they're referred from other HSAs that so much of a span would end up being reconciled like you're in. It's just operationally easier to keep on the research payer. So we haven't pushed on this too much. So that's what I'm looking for today. Thank you. So the last topic obviously is delivery reform. And so one of the areas that I wanted to ask you questions about were involved the care navigator uptake and the care plans and the lead care coordinator. Some of the percentages of uptake and percentages of high risk patients that have a lead care coordinator have a care management plan seem to load to me but I recognize this is the beginning of the process. But I wanted to hear what your goals are to get higher engagement. Sure. So we had a goal that we've articulated to our network around patient engagement in care coordination for each of the care programs and that is to achieve 15% engagement. Sounds like a small number but in our research is actually quite an aggressive number. We are on track heading in that direction. I don't know that we'll hit that target in 2018 but I think it will be in good position to be able to achieve that in 2019. On top of that we're really starting to pay more attention to some of the outcome measures that we want to see. So looking at those reductions to the utilization of admissions, readmissions, utilization increases in preventive care and those are things that we're really monitoring on a very close basis. Not only internally to look at the effectiveness of the program but being very transparent and sharing that variation from one community to the next trying to understand why we're seeing some of that. At the same time certainly we hear feedback as well about care navigator as a software tool. I think there have been some very significant steps forward in the last year. Couple of the key things that we heard very positive feedback around are the introduction of event notification. So bringing in the ADT feeds, the admission, discharge and transfer information in real time through vital as well as through a patient pain contract and that has provided value that all of a sudden has care team members saying I really want access. I want to make sure I'm on the care teams so that I get those alerts. It's also dragging the need for workload development around okay, so five people get the alert who's on first, who takes the ball and really runs with it. The other thing we've been working very aggressively on is that we've heard some feedback about how challenging it can be to be at a central computer to log into a software system to be able to access those latest updates and so we've worked really hard with our software vendor and we're in the process of rolling out a mobile app, something that's designed very differently. So just like we might download something from the Android store or the Apple store and kind of intuitively know how to use it, that's the approach that we've really taken with the first base of that mobile app and we're pilot testing it right now with our users to get some feedback and have plans for really advancing that over the course of the next months. Perfect, thank you very much. I appreciate it. Okay Marie. I also want to second, you guys have really put together a really presentation that's taking some complex things and trying to simplify it somewhat. A couple questions I had first on attribution and there's some numbers that differ throughout the time so I guess the first question is from 2018 it's on the backup. I think you had attribution around 105,106,000. And then on your slide that shows 177,000 in attribution that's like a 70% increase. And in your backup slides where you actually do some of that that's about 144,000 so you may want to reconcile. The other reason I say that is because your total dollars is going up about 35% so for one point. Yup, so there's actually a good answer. The total attribution estimate of 177,000 includes lives that were anticipating under one of these new self-funded arrangements. We don't have any spend data for those so I wanted to show really the upside number of usually we can get to yes with the self-funded models but I'm doing more of the breakdowns of PMPM spend and things of that nature. I have to exclude those lives otherwise the PMCAMs will be way out of black. So a little bit of inconsistency throughout the presentation but my intent is to really show what the top end attribution number could be because a lot of the expenses and programs scale based on the lives because that is one thing that we are committed to as some of the add on payment models being applied to every life if we're gonna do the same population of management model. All right, that's a public policy, explain that. And then when we also talk about scale on some of the goals, I think we're, we're just going a little bit. We have eight hospitals participating all in, right? We have four hospitals partially participating and only two that aren't yet when we look at the total lives right now we're at about 145,000 out of 600,000 lives in the state. So we're making progress for sure. It's just how do we get that? Because that will more ties to their primary care, right? Or to commercial. But to get those primary care is tapped in. So one of the things on your chart maybe when you talk about where we are, maybe the goals of how many are in that set because hospitals know when they're 14 I don't know how many like independent primary care where's the gap is to show how you grow. Yeah, I think that's great. And really the network development that we experienced over the last summer at least at this point of the ACO evolution is so hospital focused because we need them in to bring in the rest of the HSA. And it was really kind of all ends on that. Let's try to get all the communities in and then secondarily, perhaps, maybe you can handle with this other piece but get them into all three programs. And then I think there is a very targeted, let's look at each HSA and different providers that are there who's not in and do some target outreach in that way. The other piece on that scale is there's a lot of self-funded lives and self-funded employers in the state. And one of the strategies that we have is to work through those planned administrators and trying to bring in a number of payers in one shot, essentially, so we don't have to have individual contracts with every single employer. And then when we're talking about the total cost of care for the Medicare and then the total cost of care in the total one and where it's striving to, it looks like 2008. So when you go to your slide of the total cost of care and we talk about 3.8% increases, like 15. Yeah, when you go over the year to year, it's only a little under 1%. And I think that's because in 2018 it's inflated by the shared savings carry forward. Yeah, so this is another good question. So the way that 2019 is built is 2018 expected spend plus the trend rate plus estimated carry forward shared savings. The amount that we're able to carry forward is limited by a couple of factors. One is the 80% sharing. So essentially we're giving away that 20% that we would have been able to carry forward and maintain that link back to the 3.8% total trend. The other is the risk corridor limitation. And the initial results in Medicare is early are favorable. And between the conservatism that we had in the target plus some just good performance it seems by the network, it's looking like we might actually reduce the dollars on the table on top of the 80% share. Because she was so, really what that all means is that we're not able to carry forward enough through the carry forward shared savings to get us back up to that full 3.8%. Otherwise we wouldn't have. Yeah, where I think that also is important is on slide 21, when you came up with your calculation of the 1.9% year over year, I get enough that that works. But if I did a weighted average of the 3.8% and then the 5.5% for commercial and the self-funded rate it would be more of like a 3.3%. And I just want to make sure we're cognitive of that because we're kind of starting at a high point for 18. Yeah, and that's why I said I think some of our work together between the board and one care is to agree on how we're going to do those measurements. Maybe there's even a couple of different flavors of growth measurements that we can say, we know what we're talking about. And even weighted averages, do you weigh it just based on the number of lives or do you weigh it on the lives and the spend for beneficiary knowing that that is what generates the total dollars? The other thing that gets a little tricky in this is in the all pair model, any shared savings paid or shared losses absorbed go against the trend rate, right? And so on a pure future service basis, if you look at the green lines for Medicare, you know it's really flat since 16, a great story that it's really flat, but we will earn some shared savings against those targets and that's the reason why they need to be rolled forward and should go against the growth rates. And so if a big part of the payments for Medicare is going to be the shared savings both between the blueprint conservatism which we did earn all the way back plus additional savings to get us all the way up to our maximum quarter or that's what generates that 10,413 to 10,526. In our mind, from all pair model, being the way Medicare ought to measure what the growth rate that they actually saw was which is really 1.1%. And then just on the fixed payment and calculation I think for the fixed payment. My first question on just so I can understand the concept.  Is that all based on a fixed payment or is there any reconciliation to the possible risk for those people on a fee for service true up? So the fixed payment that each hospital receives includes both components and we show it to them in that way in some of the reports that we produce each month. The piece that is for their local lives, so if it's, you get a medical center at the Burlington Tribunal lives, that's treated as a true fixed payment not subject to any reconciliation. The amount that's referred in UVM, we do look at that through the lens of let's true this up at the end of the year using whether bill or dollars we have to do so. That second piece is really independent of any risk for UVM. Those dollars, the risk belongs to the community that attributes the life. So that spend, even though it's happening at UVM and it's under UVM fixed payment is part of the accountability of whichever HSA attributed the patient. So that nuance between what the fixed payment is is really hospital care versus the risk model which is HSA-based is an interesting one when we look at reports. Yeah, so there is this sort of balance of trade calculation for each HSA that's based on services they provide to others that come to their community. Is that higher or lower than what is estimated in the fixed payment? And then vice versa, will people lead their community to go elsewhere to fixed payment hospitals that higher or lower than will be budgeted? So it's almost a separate reconciliation. The way these fixed payment models work under the program that gives us the money is the tax identification number is either 100% in or 100% out. We can't just ask for the payments for the fee for service, you know, a Louisville fee for service for services delivered to the local population. It's everything that they deliver in the base year for the attributing population. And then Tom, we can talk about some of that. I kind of calculate that on your fixed payment it seems like it's higher than 25%, I think it's like 37. If I looked at, you had 205 million of, or even if you just had 205 million of Medicare and 110 of Medicaid, you had 330 out of 850, that's like 36%. And if you go to each area, so like Medicaid's about 50% fixed and Medicare, I mean Medicare's about 50% Medicaid or higher. Yeah, we'll take a look at it. It's even helpful for me to see some of the ways that we can slice the data that could be meaningful to you. And then the percentage that's paid not fee for service sounds like a good one.  And then my last scare is on risk. Okay. So probably it's on the risk in total. So you have $34 million of risk in total. Well, I guess the first thing is when we talk about the 2.8 million that you're expecting to put into a risk reserve, I would just challenge why you don't put that in as an expense rather than as net income and put it in because I think, you know, if you want to commit to the 2.8 and you're getting the reimbursement from the hospitals, put it in as the 2.8, go to zero. And then if you become favorable to that zero, I guess it's your choice, whether, you know, with discretion, whether that would increase the reserve. But... Yeah, I've had conversations with our audience about this one and because it's unobligated technically at the time, I mean, it's a reserve that really has no direct, it's owed determination at that point in time. It's not actually calculatable. We have a $2.8 million reserve, but you might only need a million. We don't know exactly how much. So they say, we can't accrue it as a true expense because of some accounting technicalities. But now you're actually putting it up for two different hospitals. We agree with you. And effectively that's how it works. But from an accounting treatment because it isn't funding of business expense against the current year's business activity, it's to have balance sheet to fund expense against the future year, which is a shared loss payback. That's the reason why they asked us to report that. And then I think when you talk about the risk in total, because you're expecting to get reinsurance again, correct, on Medicare? Yes, we are. And that would give, at the worst case, right, everything on every single one went way over, that would provide $10.5 million worth of benefit. That's 90% of the 50% risk in that category. So the total risk is like $22 million. On those worst case scenarios, we said it was $35 million. So just maybe because you're getting that, you may want to quantify. And then you have $5 million against that. And then the hospitals may or may not have other reserves. Yeah, and that's right. I mean, the whole risk management thing is an interesting world. And there's no guarantee that we're gonna be able to replace that policy or get that swap place that we have in place this year. So we have to have a game plan to cover $34 million of risk. So in that I don't have a guarantee or a multi-year contract that will be renewed, I do need the hospitals to sign up for this. But you're right. If we maxed out all programs at all risk under the budgeted plan to have that reinsurance risk, it would then diet it back to your protocol. But one of the reasons that's important to show it this way is we give each hospital a maximum risk limit. Even if we did have a protection kick in that minimized our total ACO risk, every hospital needs to be eyes wide open up to that maximum risk limit. Because that protection would get back and cover everything up above the maximum risk limit for them. So it's important for each HSA to really know what's the top end number for them. But you're absolutely right that in terms of the ACO payment, we could be offset in a material way through some other protection. I know that we're going to have some follow-up meetings with you guys if possible. How do we handle them and look at potentially that risk? But one thing I would put out there is, if the best estimate is what we have in there, which is right down the middle, right? And the risk quarter is on either side. Typically in the accounting world, you only go up to that best estimate. You could have overages and underages on every single line on your P&L, there's always risk. So I think it's important that everybody knows what the risk limit is and what the risk quarter is. But whether or not we actually reserve for that all or look at other metrics like cash on balance sheet, things like that, that they can provide for it. Because if you reserve for it, you just take it as an expense on your P&L and the cash doesn't go out until a later date, if at all. So it's, and we're seeing some favorability, as you said, on some of the programs which I think is great. So it's kind of efficient both sides. So I would just say that the worst fears of any person running a meeting were about 30 minut