So welcome everyone to the Greenbelt Care Board Meeting. The first item on the agenda is the Executive Director's Report, Susan Barrett. Thank you, Mr. Chair. I have a couple of announcements first. I would like to announce a recent rate decision the Board made. Today, the Board issued a decision on the Blue Cross, Boucher, Vermont, large roof filing. Docket number 131424513. The Board reduced the rate from 11.2% to an estimated 9.8%. This order is posted on the Greenbelt Care Board website, as well as all other material related to this filing. My second announcement is that next Wednesday, the Board will not be meeting, so that is June 20th. We will have a regularly scheduled meeting, however, on June 27th. And that's all I have to announce. Thank you, Susan. The next item on the agenda is the minutes of Wednesday, June 6th. I will approval. My second. It's been moved and seconded to approve the minutes of Wednesday, June 6th without any additions, deletions, or corrections. Is there any discussion? If not, all those in favor signify by saying aye. Aye. Any opposed? Okay. And Susan, are you going to tee up for the next discussion? I wasn't planning on it, and I may ask, oh, no, I won't ask anyone else. I will tee up the discussion as long as I can, but. So we're honored to have Heidi Klein here today to talk about the results from the recent State Health Improvement Plan. Assessment. That's how you do it. It's not a requirement. That's okay. Yeah. I actually, by way of an announcement, too, for me, I thought a bit of a preview yesterday, Heidi and I were both at the AHEC quarterly meeting, and so I'm eager to hear more about the results. But I think that we'll find that some of them very surprising and informed them. So thank you, Heidi. Oh, my pleasure, and thank you for having me. So what I hope to do today is just give you a really quick run through some of the data that are in our state health assessment, and mainly as a teaser, with the hope that you'll go into the state health assessment itself a little more deeply, as posted on our website. But I wanted to bring it to your attention, both to explain the way that we went about engaging a variety of community stakeholders, people who are living with various health outcomes, to look at what we know about the health status of our monitors from a population level, which then will be used to inform our state health improvement plan, which is what we're going to do about it. And for those of you on the board are concerned, it really is very much tied to the work I want that you are responsible for, and I want to make sure that you all see what we've done in service to ourselves, but also in service to you and make ourselves, meaning the state health department, available to you as you move along in the work that you do. So this is now posted on our website. It's called the Vermont State Health Assessment. You'll see in that little box on the left that there is a focus on health equity. And I'm going to explain more about that in a minute. So let's see if I can do this. There we go. So this is the vision and mission of our state health department. The vision is healthy for monitors living in healthy communities. And our mission is to protect and promote the best health for all for monitors. So we're really focused on population health outcomes. In order to do that, we are charged every five years with updating what we call our state health assessment and our state health improvement plan. And as I said, the assessment, which I'm going to share with you today, is really answers the question, what do we know about the health of our monitors? And then the state health improvement plan is, what are we going to do about it? And our improvement plan is based on a process of looking at all the data and then choosing priority areas for action across the state. Those of you who might be familiar with our current state health improvement plan, I think you are, because the goals that are embodied in the all payer model, which are related to chronic disease, substance use, mental health, are in line with the population health goals that were identified for our current state health improvement plan. So just to give you that context. And if you used to remind us on the timeline on the state health improvement plan. Yeah, so we're in the transition zone, right? Now, so the one that we have currently will run out, as it were, as soon as this new one is published. So the assessment, you'll see it says 2018. And so through the year of 2018 as well, and we're doing the update of the plan, we actually hope to have the new plan published by the end of the fall. And in that, there will be the population, the broad outcomes we're looking for, some indicators that we would want to be tracking as well as recommended strategies. And I'm gonna walk you through that at the end so you can see what our plan is moving forward and how we hope to engage the board in helping us figure out certain components of what that plan ought to include so that we can have alignment between the work that you're doing and the data and recommendations that we're pulling together. So our hope is that the assessment and plan be useful to all of our partners in the state and not, because we see it as the state health assessment, not the public health department's assessment and plan, okay? So just briefly, the ways in which I think, and obviously you will know this better than I, but the ways in which I see the state health assessment being able to inform your work is, where we are is if you look at the triple aim, which is improving care, ensuring quality and impacting population health outcomes, what we are doing is really in that third space which is about what do we know about population health outcomes and one of the best ways to make improvements. So hopefully the data that we have gathered here and I'm going to share with you can be the basis upon which you would be able to say, thank goodness somebody else has already figured out what we know about the health status of remanders we can build from there. So you don't need to do that work. I know that you all are in charge of setting hospital budgets and you are looking at the community health needs assessments that our hospital systems are doing and the data that I am sharing with you and that are in our state health assessment actually are the same data that we have given to our hospital systems. So when they do their community health needs assessments, part of it is looking at quantitative data by their hospital service area and some of it is by doing some community outreach and getting some qualitative data. We at the state health department provide them with that quantitative data. It's a series of indicators and measures that we collect and process on a regular basis and so this data that I'm gonna share with you today is data that will be given to all of our hospital systems so that as they continue to move forward with their community health needs assessments they're looking at the same suite of indicators. I think that helps us as we roll up to the state level and thinking about sort of what do we want at the hospital service area? What are we looking at the state level? We try as best we can to ensure that we're looking at the same data points. And then as I mentioned earlier the current priority areas in the current state health improvement plan so the one that's going to end in 2018 actually were the foundation for the population health outcomes and measures in the all pair model agreement. And so clearly there are additional indicators because we didn't look at clinical measures. We were looking at population-wide measures but it's the same set of goals to say what do we know about the health of Romaners? Where do we see that there are priorities? What should we be doing about it? I think the only other thing I want to let you know in case I skipped it too quickly is that in doing this work I'm going to share with you how we actually looked back at the current community health needs assessments of the hospitals in order to inform our state health assessment and set priorities for moving forward this time around as well. Okay. Hi, before you move on I just add one suggestion to your previous slide and talk about another area of synergy which I think is as we work towards a revision health resource allocation plan I think this data really becomes a core piece of the needs. Absolutely and in fact I was going through I met last a couple of weeks ago with Jessica and Michelle on staff at the Green Mountain Care Board to sort of let them know the types of data that we have available at the health department that might be useful to the health resource allocation plan. Much of one core piece would be the data that are embodied in this health assessment. Thank you. So what process did we use? We started with a series of questions which are sort of what are the key health challenges in Vermont? But looking beyond that in public health we always ask well not only what are the health issues that we're seeing but what are the contributing factors and I'm going to share with you the frameworks that we use to think about contributing factors. I know you all have had some conversation about the social determinants of health. It's just another way for us to think about contributing factors is different language but same intent. And then we really committed ourselves this time around to looking a little more deeply instead of just looking across all the population really looking a bit more deeply at which populations are affected. So when we do our data collection we are able to break down our data by geographic distribution. So we always run our data by county. We run our data by hospital service area and then by the state. So we always have those three geographies. We always run to the extent that we can by age and by sex. We don't necessarily consistently run in other ways and we challenged ourselves this time to run our data a little bit more a little differently because we wanted to say that you know what there are some other populations that have specific characteristics that might be important to us to be looking at that we wanna look at. And that's based on our commitment to looking at a few things. So I'm gonna get to that population focus in a minute. The reason I included this one is just gives you a flavor of how we think in public health and the work that we do. It's a basic description of not only do we look at the data, like what does it say, what do we know, but why is this happening and therefore how are we gonna deal with it? So each time we ask why we come up with a different how because ultimately the value of the data is telling us and directing us where we need to go for improvement. But it has to be based on good data and a questioning of what's happening underneath the data in order for us to move forward. So I think you all have seen this framework before. It comes from the University of Wisconsin. It's the population health model that's been touted by the county health ranking system. I brought a copy of the county health rankings report for the state of Vermont. It's been published for over five years. They do it. And what they do is they compare county to county. It's somewhat useful in terms of the data. We actually have more rows of bust data than they have but I bring it to you because I think this framework is really useful and we are trying to use it in what we're preparing for you. Cause it shows how our health outcomes are based on certain health factors. So those health factors are those four buckets in the middle, health behaviors, assets to clinical care, social and economic factors and the physical environment. So when we say, well, what's contributing to these health outcomes? These are the things that we're asking. If you keep asking like going one step back on your health behaviors, we see it's tobacco use, diet and exercise, alcohol use, sexual activity. None of this is probably surprising to you. But I just wanted to share this with you cause it helps to ground how we decided not only to look at the health outcome data but we started looking at some of these health factors in the data that I'm going to share with you. And it gets at how do we begin to link what we know about our health system functioning, our population health outcomes and the conditions in which people live. So those social determinants of health which is a lot of what that last column really is when we start looking at those things. So it breaks it away from big categories into a way of trying to get our heads around what do we actually measure? Okay, these I just thought was very fascinating. Everybody always wants to know how do we fare compared to another place? So county health rankings enables us to, again, they're using all of our data but they've put it together nicely to show the differences in our communities statewide. So these are the maps that you would find in the county health rankings data. They do rating based on and ranking based on the health outcomes, those sort of what we're seeing in terms of morbidity and mortality and what we're seeing in terms of the factors that contribute to those health outcomes. And you'll see they're by and large aligned. The shading is very similar. There's a couple of liars. Again, I'm gonna go through this really fast. It's mainly to hopefully tease you to look a little deeper at the data. This is now in our state health assessment. We have at the first section is about overall health status and statistics. And so this is population wide. I thought these are some items that might be of interest to the board. You can see our leading causes of death. I don't think any of that's going to be surprising to you particularly given your focus historically on chronic diseases, cancer and heart disease being the two most important. Those are also driving our healthcare costs as you know as well as the demands on our healthcare system. In large part, you'll see to the right that are the leading causes of hospitalization versus death and you'll see injury and poisoning spiking up there. I love the way we had to draw this bar chart with a little break to just show you how off the chart. Actually the numbers are comparatively for injury and poisoning compared to the respiratory diseases which are actually the health outcomes that lead to death. I think this is usual information for our health systems folks to take a look at. The other item is another way that we often look at things are years of potential life lost because we all die of something ultimately, right? But what we really are looking for when we're looking at years of potential life loss is really the potential either for prevention, preventing an illness or at least improving the quality of life for folks. And that's what this years of potential life lost are. And so you'll see cancer but again, unintentional injury is right at the top of where we're seeing people dying prematurely and where we have opportunities for prevention. So cancer, unintentional injury, heart disease and then their suicide. So this just gives you a sense how it compares one issue to another because oftentimes it's easy to jump in with some assumption. Another piece I really wanted to point out to you is quality of life. And so you'll see this comes from our Behavioral Risk Factor Survey. So this is a survey data. It is a sample but we do feel that it represents Vermonters overall. And we have been able to look at data based on those who report poor physical health and poor mental health. And this is just to give you the beginnings of a preview of how we are able to break down our data. The difference we're able to look at age category. We're looking at educational status and then we're looking at our Vermonters of color versus our white Vermonters. And you can just see some differences. They're not statistically significant in the way that I'm showing you here necessarily. But again, this is just to give you a sense of overall and the kind of data that we're able to share with you. All right, so I talked about the fact that we actually wanted to look at which populations might be most affected. And I don't know how much the questions and issues of health equity have surfaced in the work that you are doing but it surfaces a lot in our world. And so we came to a shared definition about health equity and that is looking at people who've experienced social or economic disadvantage, historical injustice and other avoidable inequities that are often associated with the categories of race, gender, ethnicity, social position, sexual orientation and disability. So we know both through the literature, through the data that's available nationally and then some of our own local data that these categories often experience greater health impacts at a disproportionate rate than those who are not in one of these social categories. And we wanted to look to see what did we know about what's happening in the here in the state of Vermont and would those therefore be areas where we need to target our interventions. Cruising now because I'm just gonna go whiz bang, right? So race and ethnicity, we decided to look at so what about our people of color? I think this is one of the more fascinating, this is not a health data slide but what this tells you is by looking at the data it helps us get past some of our assumptions and why we strive to be data driven. The common assumption even within our department is that we have no people of color and if we do, they all live in Chittenden County, right? It's a Burlington problem or Rewanewski and I'm sorry to say a problem is how it is often framed. What I think this is really interesting is this is just straight up census data and it shows you that are basically our population of color has doubled over since 2015, excuse me, 2000 to 2015 and there has been a growth and spread across the state. So it is no longer just Chittenden County and it is not huge, we still have 7% but it's doubling and the rate of growth is pretty significant for our small state and I think we need to take that into consideration as we look at our population and statistics and what it means. I also want to let you know I think one of the most important things for this because we also looked at our LGBTQ population and every time I am asked the question I have said so where do you think our LGBTQ fair compared to our people of color in terms of just sheer population numbers and almost every time people say double. I think we have double the amount, right? They'll say oh 15%, you know, people will say well some people will say well it's one in 10 so people will say no, no, no, it's higher than that. It's actually the same. So we just don't see people of color for some reason but we see LGBTQ issues all over the place. We don't see these issues so that was a good pause in learning that we got from doing this research. So for our population of color we looked at access to care, we looked at quality of life. You can see the categories. We're able to collect and report on data and I think the first one is about has a usual care provider. This is a doctor in the last year. You'll see there's not a whole lot of difference. We do very, very well with health care access in the state. You know that and you lead that and we're really proud of that. However, if you look at quality of life what you'll see is some fairly significant differences by racial makeup and what I will call out to you is the differences here in self-reported poor physical health and poor mental health amongst our Native American population and our mixed race population. So I'm pointing this out because this is a pattern you're gonna see throughout our data is that those two populations if we are looking whether it be on reported poor health outcomes or what we call risk behaviors, behaviors that would put you at risk of poor health, these two groups stand out as being in a different place than our other populations. If you look at it again, so here's depression among adults. Again, this is what you're seeing. The highest numbers are rated by our Native American and our multi-racial population. The protective factors, those things that are good, the people that our youth are seeing in their lives and this includes talking with parents about school at least weekly, spending 10 or more hours in the school activities, having teachers that care about you. These are the things that you've probably heard when you have heard presentations about ACEs and those early childhood events and how that sets one up for either positive or negative health experiences. What we are seeing here is our populations of color are reporting fewer protective factors than are white non-Hispanic. That's important for us to be looking at what's going on there that they have fewer protective factors and what is that therefore going to mean in terms of their health outcomes and their health needs over time. The LGBTQ identity, that was another area that we were looking at, access to care as you'll see. We're looking at LGBT in the dark, girl blue and heterosexual and the lighter, not a whole lot of difference in terms of folks reporting access to regular care. But if you look at quality of life, which are those pie charts, there's a pretty big difference between what our LGBT folks are reporting and what the heterosexual community, those who, and this is percent of adults who report fair or poor health. So these are not what we would like to see. Gender orientation, this is just to give you a sense of who are our LGBT? What is interesting to see here is just we do have, if you look at the overall numbers, remember I said we only have about 7% of LGBTQ in Vermont, that's the total. But if you break it down by category, you'll see that the highest percentage is in our 18 to 24 year olds. So we expect that as time goes by, we actually might have a higher number of folks reporting LGBT status overall because it is now something that people feel comfortable reporting or they perhaps didn't before. We're looking at sexual health risk behaviors in that right side. And I think what is important to see is the difference between our LGBT and our heterosexual populations. On those who have had sex before age 13 or have had any high risk HIV transmission behaviors. So we see a significant difference that's concerning to us in terms of potential health outcomes. Depression. So we're looking here at the difference. Reported sad among high school students is on the left. The adults diagnosed with depression, you can see the differences here between our LGBT population, our heterosexual. Those are significant differences in terms of mental health and depression. This one is, this is one of those, the next one on the right hand side is one of the things that I don't understand. And just, I just don't personally, thankfully have any personal experience with intimate partner and sexual violence. And I looked at this day and I thought, oh my gosh, what is going on here? If you look at the LGBT versus the heterosexual, look at the difference. So adolescents hurt by someone they were dating in the last year. That's that first bars look at 24% of our LGBT versus heterosexual, which is 8%. It's still high. Let's just be clear. Like we shouldn't be seeing this, but 24%. Adolescents ever forced to have sex, 24% in our LGBTQ and adults who ever experienced intimate partner violence, 32% among our LGBT. That's, so these numbers are appalling. If you further wrote that down by gender, what would it be? That's a really good question. You know, I don't know, but I can find out. Yeah, and I'm quite sure we can run that statistic. So I'd be glad to ask someone to do that just. So tobacco alcohol and drug use. Again, we want to see that we're risk behaviors different among the people who identify as heterosexual versus those who are LGBT. And you'll see in adolescence and in adults, there are differential reports of smoking, binge drinking and marijuana use. So those risky behaviors are showing more in our LGBT group. The protective factors for youth. Again, on the left are LGBT students. On the right are heterosexual students. And there are those who are LGBT report fewer protective factors. We know that that's a setup for a lifelong challenge. People living with disabilities, I'm sure you've seen some of this data before. I know that we have very active and engaged folks, which is fabulous and they've been working with us as well. Initially, we just have some basic statistics about what percent of folks in Vermont are living with some kind of either intellectual or physical, excuse me, cognitive or physical disability. So you can see just the straight up numbers. And you'll see that our people of color and people who are LGBT as adults have higher numbers of self-reported disability. I don't know why, that's a good question. Again, so asking the why will help us figure out the how. The type of disabilities, this is probably familiar to you, but we will have this data available. So you can see the difference between the cognitive, hearing, visual, mobility, independent living and self-care. The highest rates right now are in mobility and cognitive. But what I would point out here is it's showing them as discreet when often it's multiple, right? They're not usually discreet disabilities. We were looking at, again, we tried to do the same questioning for each of our sub-populations. So we looked at access to care and quality of life. Not a huge difference on access to care other than dental care here. And you'll see throughout that access to dental care has is an enormous challenge. And it in fact comes out as one of our priorities for moving forward is oral health. Quality of life, we are seeing a significant difference in self-reporting between our members of our community who have a disability versus those who have no disability. That's what reporting fair to good health, fair, excuse me, fair to poor health or being diagnosed with depression. These numbers are very, again, really frightening. Risk behaviors, this again is looking, we're trying to say, they're looking consistently about what we know contributes to health or doesn't, smoking, physical activity and nutrition is looking the difference between those who have a disability and those who report have not having one. I'm not sure that any of these are statistically significant other than the smoking. But that's still alarming. As we know, it's one of the three behaviors that contributes to the four chronic diseases that account for 50% of our deaths in Vermont. So that's significant.  So our people who are living with a disability have higher rates across the board for chronic disease. We looked at social class and social economic status. This is just sheer demographics on this one. So I'm gonna jump over it, but it's just helpful to ground what we know and how we've defined using the federal poverty levels to talk about economic status and people who are living in poverty. And then we decide to look at quality of life, right? We've done this for each of them is there a difference? We didn't do access to care for this one. I don't know why. I apologize, but jumping to quality of life, looking at the difference between those who report fair or poor health, physical or mental health and then reporting depression. And I'm gonna pause here for a second because this is basically what we see in every single slide, these curves, right? So the, those who have fewer, who have access to more financial resources generally report better physical and mental health and better, generally report better health outcomes, right? So it's about how people feel about their health as well as the diseases that we have looked at and the health outcomes we've looked at. And by and large, we will see the same thing based on education, right?  What we also found, and it doesn't really show, here's this question of the interplay between income and education and from what I understand from our statisticians, education is more important than income in terms of adopting healthy behaviors. So even if you have a lower income but you've had a higher level of education, you're more likely to adopt healthier behaviors. And the thing that is not here on our racial makeup that I wanna go back to is, if I can, there we go. In poverty, we don't have this slide, but reported nationally and that what we're looking at too is if it plays out here. And that is that our people of color, even if the higher income still report poorer health outcomes than our poorer white members of the Vermont society. So I hope, was that clear the way I stated that? Okay. So it asks us to care.  The difference based on financial means and educational attainment. Not huge differences here, other again pointing out that we are not doing a good job with access to dental care. The cost to see it with health care, we want to see if that had anything to do with why people are getting care or not getting care. And if it mattered, if high school, excuse me, if your educational attainment mattered, as you'll see, there's not a huge difference here because we do so well in ensuring people and making sure people have access.  Student connectedness, this is something that we look at again, again it's part of this whole framework of protective factors in childhood. I think this one's really important to look at because this actually does show some really interesting things. Again, these are students, so let's just remember that in grades nine through 12 who are reporting how they feel connected or not. This is not a time of life that most people feel connected. Like let's just take that as the bar. So I'm not surprised that we see somewhat low percentages here but I think the differentials are what's important. So we see that in terms of connectedness, our heterosexual youth feel 53% feel connected whereas our LGBT folks only 31% feel connected. Connectedness is really important in terms of mental health status, quality of life and the adoption of risky or non-adoption of risky behavior. Connectedness is hugely important. Smoke, and I'm gonna switch over here. This is one of these really interesting ones. I think if you look over here is smoking during pregnancy. We look at this a lot. This is one of those data points which I forgot to mention the criteria for why some things are in this report and other things are not. We asked our data analysts to look by our populations of concern but we also said point out places where you know we're not doing as well as our counterparts in other states are where we're going in the wrong direction. Smoking in pregnancy is one of those data points. We do very poorly on smoking in pregnancy among certain populations. And it's a really hard nut to crack. Does that manifest itself on in disproportionately high and low birth weight babies relative to the rest of the birth weight? We actually do really well in Vermont in terms of low birth weight. And our birth rates are so small, are so small statistically. We have a hard time parsing that out but I do know we pulled together specialized data which I can send to you after this around low birth weight. Somebody else had that same question. So rather than trying to answer it, I'll send you the actual data if that's okay. Sure. And then this is just some of my fun data. My fun data as in things that surprised me. First of all, it is outstanding to me and scary that 48% of pregnancies in Vermont are unintended. 40% of our pregnancies are unintended. That's huge. We should be looking at this. I didn't know that. And then not surprising I would say, 86% of the highest rate is among our under 20 age and among those who are less or indicated. But we still have 49% of our some college educated women who are having unintended pregnancies. We just think that's something we should be looking at. Really interesting. Youth eating habits, this is one where I meant this is important. So this one actually flies in the face of our assumptions. If you look at which populations in high school are actually doing better than others in terms of their fruit and vegetable consumption, which is our behaviors that we really want to see. It is actually our black, our Hispanic, almost all of our populations are doing better than our white non-Hispanic in actually eating as we promote. And it switches when you get to adults. And so the adults, it's just fascinating. Fascinating data. And again, the reason to share this is always to say, so what is it telling us and why are we seeing this data and therefore what are we gonna do about it? This is one of my other favorite ones because it flies in the face of what we do to suit. High risk drinking behavior among older adults. As you are wealthier, you drink more. As you have more college or more education, you drink more. This is not the story we tell ourselves, right? So this is really important data. Again, let's not make assumptions and let's say why is that, right? We could speculate, but we probably need to dig a little deeper. So I'm gonna switch now from the data that I'm planning to share with you. I did, at the very end of my slide deck, give you the link online to the full data set. And because I only gave you a teeny, teeny smattering, what I didn't give you at all, frankly, was the data by disease, right? So I gave you the populations and focus section. We also have sections on chronic disease, substance use, early childhood, environmental health, infectious disease, all of those that you can go into and see, but I really wanted to give you the sort of populations and focus so that you could see how we've been trying to work the data a little bit differently. And again, get closer to what is it that we actually know about the health status of remandros, and which populations are most affected by things. So that's the data that I shared with you today. Where we're going with this is we then sort of said, okay, of all the data that we've looked at, what do we know to be the priorities, right? So in order to get a state health improvement plan, which has three to five goals, you have to look at all the data and then window it down. So our state health improvement plan will have outcomes indicators and strategies. Did I tell you, Pierre, I think I did. These are the five priorities that came out of the state health assessment. And just so that you know, the way that we governed and made these decisions, we had a steering committee that included the secretary of the agency of human services, our health commissioner, the director of one care of remand, the director of building bright futures, and then a health equity leader, Mercedes Avila, who serves as our steering committee. And then we engaged 180 stakeholder groups to help us figure out what data to look at, actually read the data and then identify their priorities. And through three different priority setting sessions with those advisors, we came up with these five areas of focus for the next state health improvement plan. Three of them are very familiar to you because they're already part of the existing state health improvement plan. So those will carry forward, maybe with some more granularity in terms of which populations we wanna focus on. So for the state health improvement plan, chronic disease, you heard me call out, for example, our populations living with disabilities. So we might have a focused area on that. Substance use disorder, we might be looking at mental health, we might choose to be looking at our LGBTQ population in addition to the population at large. Oral health was the number one issue identified by our community partners in need. And that's because that is where we lack access to services. And because oral health is affected by and then reinforces cycles of chronic disease and cycles of poverty. So that was one. And then early childhood development because we all know that if we really wanna move upstream into prevention, this is where we need to focus some of our efforts. And so there was a real desire to make it a part of our state health improvement plan overall and figure out how we make those connections with the good work that's already happening but how to be connected, make the connection between early childhood, exposures, investments, behaviors and long-term health consequences. So these are the priority outcomes that we'll be looking at. We're gonna use, so for each of those, so we may have like an overall area of focus, those five areas. For each of those, we will be identifying a series of measures like we're an indicator sort of targets of where we wanna be. And then we'll be coming up with strategies to try and change, make change. And I'm sharing with you this framework that we're gonna be using because I think it will be helpful to you. Some of you may have seen this, some people call it the John Ourback model, but when we move to it, we recognize that, remember if we go back to the idea of what contributes to health and where do we need to sort of focus our efforts. It's clear there are three places that we can focus our efforts in that intersection of healthcare and public health. So one is looking in our healthcare system. So that first bucket as we call it is what are the changes that are needed in our healthcare system or in the clinical setting to improve health? The second bucket is where is that integration? And I know you all have been thinking a lot about this between clinical care and community services writ large. And so a lot of the integration work that you've been doing and care management has been related to how do we connect physical health services with mental health services with substance use services with some of the social services that people need in order to be healthy such as housing, transportation, access to food, et cetera. That's that second bucket of sort of making sure the individual has the full range of care and services. And the third is really what do we need to do population wide for prevention, which is usually the sweet spot for public health, right? And that gets us also into the work that we do with our non-health related partners in transportation, housing, et cetera. So we will be looking with support from multiple stakeholders and in dialogue with you in particular for what are the measures we should be looking at in the clinical health system and in that integrated system between health care and other social services and then what are some of the strategies we should be looking at. And we'll be looking at those across the five areas if I'll go back for you, if I can. Across these five areas, what are the strategies in each of those three buckets for these five areas of outcome? So that's what we're going looking for. That's the work that's gonna be happening over the summer. I leave you with two things. One is this is the vision that will be informing the state health improvement plan. And I share it with you for two reasons. This came from those 180 stakeholders. This is not our vision at the health department. We asked them what in five years if we've worked successfully to achieve health equity, meaning health and equity, what would it look like? The vision is all people in Vermont have a fair and just opportunity to be healthy and live in healthy communities. And then these are the values that they set forth. I wanna share with you the right hand side, those are the conditions that are necessary in our community. So for those of you who've been thinking a lot about how do we connect our health care system with the social determinants of health is about connecting with those sectors. And we, the health department are doing that through the health and all policies task force of the governor. And so they're gonna be using the same rubric and the same way to look at what are the contributions that other sectors can make towards creating the conditions in which health can thrive. And that will be in that third bucket of strategies. We'll be looking with them too. So I think that's all I'm gonna tell you. I think I probably went over time and I apologize. The last slide has lots of links for you. So the full report that looks like this. But if you want to go to data that's beyond this report I've shared with you a few places where you can find them. So there's the scorecard for our existing plan which will show you how we track, we set goals and indicators and how we track whether we're getting there. So it's the accountability system that's built in to our state health improvement plan which will be the accountability system that will continue just with new goals and indicators. I also wanted to share with you the community health needs assessments by health service area, hospital service area. So I think that's important data for you to know that we have and that we pull from and we used in identifying the data for our state health needs assessment and informing what the priorities were. So we looked at the priorities set by each of the community health needs assessments and we're holding those up in a core criteria and setting priorities.  What's in those data sources, how we can run them and it gives you a point to person. So those of you who love data, that's a good place for you to go. I am done. Thank you. Any questions about this report? I just have a question on, it's very interesting data. As far as the sample size and the self-reporting, because in certain areas, I would imagine the sample size is really small, start cutting it down. So how reliable is that data? Probably particularly when you get into ethnic groups and ages and things like that. Yeah, no, it's a fabulous question and honestly it's one that we've been really cautious about running our data in the past because we felt like we wouldn't have adequate for comparative purposes, right? So there's the what can we report without, frankly, making it so easy to identify because of our small populations, right? Versus what can we report reliably? All of our survey data were very confident that our samples are representative of the state because the main surveys that we do are the behavioral risk factor survey, and these are the self-reported sampled data are the behavioral risk factor survey and the youth risk behavior survey which we have been running for 20 plus years and the sampling strategy has been vetted and approved by the Centers for Disease Control and Prevention. We're really pretty confident on those samples versus the census data where we can say we feel like we have data across all of our monitors and some of that is pulled from more of what we would call our census data sources and where we don't have enough data we will say not enough data to report. And it's also why you'll see that a lot of the data that we did not charge ourselves was saying whether something was statistically significant. That's where that would matter and we haven't done that. So we are reporting sheer percentages without saying whether it's statistically significant because that's when do we have all the right people? Do we feel that we're comfortable, that it's reliable, that we can do that? Thanks. Any other questions or comments from the board? Actually, just a quick one. Yeah. First of all, thank you. This is tremendously helpful and you've been helpful as we are starting this process of reimagining the ATRAP and I think as Robin was saying earlier you and I have talked about this is gonna be so foundational for that work. We can hopefully build on and collaborate so that we're working on all this together. One of the pieces that I should just drop me and as I was looking at this now was if you look on your page eight squad with that framework for thinking about policies, health factors, health outcomes and with clinical care, it's access to care and quality of care. Sorry. No, that's okay. I'm gonna keep going so that everybody can see it. Here we go. Yeah, just the clinical care and the two components to thinking about clinical care, access to care and quality of care. And I always struggle with how do you measure, how are we measuring quality of care? Yeah. You know, people with dissertations and books and then come up with measures and all that. And as I was thinking about your framework for strategies here, you have this bucket of traditional clinical prevention which is obviously gonna be an important component of the framework. And then I guess then I went and was looking at the vision and the core values are around equity, affordability and access. And the services, making sure that the services are available, accessible, affordable, coordinated, culturally and culturally appropriate. It just struck me that quality is not in there. And so I was just wondering, how does that, how does you have to bring quality and thinking about quality of clinical care and then putting it in the framework? I think it's a really important thing to point out. I would say that in the world in which we live in public health, which is less service and care oriented than these other things, quality of care is not something that we think about. And so I think the fact that it's not in the vision statement is an oversight. It was a fact that it did surface in the conversations that we were having. Other than when we did some focus groups. So we did, we went out when we did focus groups with populations, our focus populations of people with disabilities, LGBTQ, people who are living in poverty and then our ethnic and racial. They talked about quality of care, but they didn't talk about it in the way that we do. Their quality of care was about being understood and being respected. So it's more like that patient experience, quality of care as opposed to a differential measure of like whether or not a provider is following the best practice with the clinical procedure. So it really didn't factor into what people were talking about, which is why it didn't come out. I don't have a better answer for you, but it is interesting, it is interesting. And I just also want to come back to this here because one thing for those of you who are geeks like I am about getting your percentages right, the thing that really makes me crazy about this one is it actually shows that clinical care is worth 20% of the contributors to health outcomes, but actually if you look at it in most of the literature, it's 10%. And the reason it shows that it's 20% here is that genetics is not listed. So if you take out the percent that is genetically connecting to your health outcomes because the idea was well, you can't change genetics, but you can change these other things. Health care then gets a higher percentage rank, but we actually know that in terms of actual health outcomes, those things that contribute to or prohibit positive health outcomes, access to and quality of care is actually only 10%, which is always shocking because- But that's what all money goes. Yeah, well. And let me say, we initially didn't think we would talk much about access to care and care at all, and our previous state health assessment and improvement plan didn't include access to care or quality of care because we were always talking about prevention and upstream. That's where we live and focus in public health, but we realized that if this is going to be a plan for the state and not for the health department, what we heard from the folks we talked to is access to care is essential. And what we heard particularly from the populations in focus that until we deal with issues related to access to care prevention is not a priority. And so in order to be respectful of what we heard with everyone we engage, we realized, oh yeah, it has to. And in order for it to align across all of our state planning efforts, it has to because we really wanna make sure that our state, what we produce as the state health plan works and aligns with the work that you're doing and the work that's being done on the health system reform at AAHS and works with our other partners. So that's how we get ended up with the three-bucket approach. I have a question to comments. If not, this time we'll open it up to the public. I'm gonna start us off, Dale. How are you? Well, why the pregnancy, and this is more of an edit. What slide are you on, Dale? I'm commenting on the slides in general, but just commenting about the slide that shows the pregnancy. 48%, we had three children. If I was filling out that form, all three would be unintended, because what caused the first one could probably, I mean, so I'm like, hey, we're 100%, we're not 48%. So I'm not quite sure what to think of that in terms of how you measure that. That's just an edit. The other one is, oh, culture in terms of the Native American population. I'll never forget, my dad showed up to watch a track meet and all the Native Americans of the ABC program, they were all trying to figure out whose dad he was in the program. He was mine. And seriously, it was the funniest thing he ever saw. They were all looking at everybody else because he's not white, and he's my dad. And you should have seen the shock faces when they found out he was my dad. Like, wow, wait, he lives in Vermont. Yeah, we're in Vermont. So I think you're gonna know where I'm going. When it came to measurements, because my mom was Irish, they didn't allow you to record Native American back then, and you still have that problem today because of the assimilation, even though you can see it when you go into the culture. So is it that small a population? Because you can measure it on the reservation, but it goes way beyond the reservation. Absolutely, and I think when I take from all the data, really is sort of what is it telling us, is it telling us the whole story, right? And what do we need to know that's driving that? So for our Native populations, I think we have enough here to say that there are differences in their health experiences than our other populations. So regardless of the size and whether it's full, that we fully accounted for everyone, there's still reason to be looking at that. And that indeed, we may find that there is a larger population than our self-reported in the data that we have, because we're reliant on the census data for that. But there's enough here to give us pause. Thank you that that is true. I really love to hear that happening. The part B is when you get to the social determinants of health within this population, and I've heard this one whole life, and it's thought, as I talked with my friends, the culture disassociation had a profound effect on the social determinants of health, which creates a different metric for how do you measure that impact? I think one of the things that we charge ourselves using the health equity lens that I didn't really speak very much about is, where do we know that historical discrimination and justice, which is true for our native populations? How that actually leads to differential access to the social determinants. So if you are a native American, you have a differential access to housing, transportation. You are more like those things that are the conditions of healthy living by virtue of the fact that you're native American. So we know that if we look at, from equity, we look at race, gender, and poverty. Those three things, so our health outcomes are here and our social determinants are there. What's not on this chart in this framework is the fact that access to all of those things in that middle box are determined and influenced greatly by those three primary issues of race, gender, and class, which we don't like to talk about either, but that's, you know, we use the word poverty, but it's really systemic class issues. Those three set you up for either living in communities that have the infrastructure, the resources for healthy conditions or not. And we really need to look at that at a policy level and not think of it as a problem of the individual. That's a structural problem. Any other questions or comments? All right, well, thank you so much. I love sharing this data as you probably can tell. I'm happy to follow up in whatever way. And I do hope that you find it useful in your deliberations and as Susan knows and her staff know, we are more than happy to collaborate whenever we can to make sure that you have the data, as well as what we know about what works for health. There's a lot of conversations where our healthcare system is now being held accountable for things that happen outside traditional medical practice, right? And so a lot of the, like what works for prevention, what works outside the clinical setting is where we live in public health. And so we're happy to be partners with you when it comes to strategies as well. Great, we look forward to working with you as well. Thank you. Thank you very much. Do you want me to do anything about that? There's some new answers, I don't think. Okay, well, we're gonna come up. You live in Sierra, we hide. Yeah. I don't live in Sierra, we hide. Cheers. Cheers. Cheers. Cheers. Cheers. Have fun with me, do you see what happens? Yeah, I will. Actually, our several teams will. So we're gonna be speaking with you about generally a regulation of accountable care organizations and walk through the major regulatory activities that are going to take us all through to 2019. Before I get to the agenda for this presentation, I just wanted to remind you that 18 BSA 9382 and rule five distinguished between two processes. First is ACO budget review, which is obviously annually with ongoing monitoring. And the second is ACO certification, which is done once with annual verification by the board. So here's the agenda to give you some context for the ACO budget guidance that we're gonna walk through. We'll start by reviewing criteria for the board's review of ACO budgets. And these include statutory criteria, as well as the requirements of the all-payer ACO model agreement. Next, we will discuss the regulatory processes we know are in store for us between now and 2019, namely reviewing ACO's 2019 budgets and payer programs and verifying one care's continued eligibility for certification. Next, we are going to walk through the ACO budget guidance and reporting requirements for 2019 that we have drafted, including a proposed timeline for public comment and your vote on that guidance. Sorry, this is a busy slide. Rule five, the administrative rule that took effect last year, says that in deciding whether to approve or modify an ACO's proposed budget, the board will consider the statutory criteria in 18 VSA 9382, as well as any applicable requirements of the all-payer ACO model agreement. There are 15 statutory criteria, really considerations that are listed in the statute. I didn't include them all here, but I did include some examples, and they are information on utilization, the extent to which an ACO provides incentives for investments to strengthen primary care, the extent to which an ACO provides investments for integration of community-based providers in its care model, or investments to expand capacity in existing community-based providers, the extent to which the ACO provides investments for incentives for investments in social determinants of health and information on an ACO's administrative costs. As you all know, the all-payer ACO model agreement includes a number of requirements that are applied to the state, but that obviously guide the board's regulation of ACOs. And these requirements include a Medicare total cost of care per beneficiary growth target, and an all-payer total cost of care per beneficiary growth target, which is a compound annual growth rate of 3.5% or less over the five performance years of the agreement. The agreement also includes minimum standards for what types of payer programs count as scale target initiatives. It includes targets for the number of Medicare and all-payer beneficiaries aligned to these scale target initiatives. It requires reasonable alignment amongst payer programs in key areas such as attribution methodology, quality measures, and payment mechanisms. And finally, the agreement includes several population health goals and a number of quality targets underneath those population health goals. So before we start walking through the 2019 budget guidance, we wanted to briefly discuss some process considerations. So it is possible that an ACO other than one care could submit a 2019 budget for your approval if the ACO planned to participate in a program with Medicaid or with a commercial insurer. They would also need to be certified by the board. A Medicare only ACO would not need to be certified. So we have not heard of another ACO possibly submitting a budget, but since it is a possibility, we chose to develop two versions of the ACO budget guidance. One that is specific to one care and another that is generic. Both versions were based on the ACO budget guidance that you approved last year. However, the obviously one care specific one is tailored to one care's model, which we learned a great deal about last year. And we felt that this approach would allow us to be more efficient and get the most useful information we could from one care in the initial submission. So today, we'll be walking through the one care specific guidance. We will have the generic version of the guidance up on the website if it's not already for folks to comment on and review. I think there's a missing slide, but. So the other process that we're gonna definitely have to undertake in 2019 is to verify one care's continued eligibility for certification. So rule five says that once an ACO is certified, it has to annually verify that it continues to be eligible for certification and it has to notify the board of any material changes to its policies, procedures, programs, organizational structures, health information infrastructure, or any of the other matters that are addressed by the certification statute or administrative rule. So we have drafted and you should have it in your packets a form for one care to complete and submit to us because ACOs could be very different from one another. We would anticipate creating an ACO specific form like this for each ACO that the board certifies that would be tailored to the documents we have received during the initial certification process. So the form that we developed for one care asks about, like I mentioned, changes to the key policies and other documents that we reviewed earlier this year. It also asks for updates on issues that were raised during the certification process. So for example, one care mentioned that it is planning on adding a condition specific content to care navigator for patients to access and we want an update on how that's going and progressing, things like that. Finally, and very importantly, we are asking for an explanation of how one care complies or plans to comply with the new statutory certification requirements that Susan covered the other week in the legislative wrap up. And so now we're to this slide. This slide and the next restate those statutory amendments. The underlined language is the new language, obviously. I won't read them, but essentially, this change relates to parity for mental health care. The first bullet here relates to what's referred to as pay parity and the last bullet, second bullet there relates to preventing and addressing the impacts of childhood adversity and the ACO's efforts and connections in that regard. So our plan is to run this program certification verification process concurrently with the budget review process. So we would require one care to complete the form on or before October 1st, 2018, which is the same date that we would be requesting their budget submission in the guidance that Melissa's gonna walk through. Pursuant to rule five, we would then have 30 days to notify one care if we need additional information. One care certification would remain valid while the review process is pending. If there are any problems that are identified during the review, they could be addressed through a corrective action plan or other remedial process such as a monitoring plan, whatever the board feels is appropriate. The final bullet there, considerations for rule five update is just to be clear that we are, we do expect one care's policies to change in early 2019 to reflect it's updated or new payer programs and the requirements of those programs. And if we want to know about those changes prior to October of 2019, it may make sense to, I guess, enhance the section of rule five that requires an ACO to automatically notify the board of certain changes. I think I've talked with you about that section before, but that's something we are talking through. We are still talking through potential amendments to rule five, and that's one of the areas we're looking at, I guess. So Melissa's gonna walk through the one care specific. Hi everyone, up in front of us is the table of contents for the 2019 budget guidance and reporting requirements for one care Vermont, and it was a collaborative effort between our policy team and our finance team and our analytics team. So we have everyone here to speak to their respective sections. So we began the development of this guidance by reviewing one care's submission from last year, which we built through a process with key stakeholders and our actuary and also reflected on the Green Mountain Care Board's hospital guidance for this year. Anything that was in the certification section that we approved in this past year has been moved to that verification form that Mike spoke about, and so this year we have streamlined the guidance as much as possible to focus on the ACO's model of care and the relationships with providers, payers and the community, and also to provide guidance on the all-pair model requirements, and as you'll see at the very bottom of this, we have a test year for the primary care spend measured by payer and non-claims and non-claims specification, which Michelle will walk through. So the timeline for the submission for this year is we have a starting presentation to you today, then public comment from now until June 30th, which is up on our website. We plan to come back in front of you to discuss any public comment that we received and any possible changes on July 11th. If there are no changes proposed, then we would discuss the potential to vote on the guidance on that date, and we also have July 18th where we would come back if a July 11th is not a date where we would vote. The timeline below it is subject to change at the moment because we're still finalizing some of the dates in November and December, but we will plan to release this by August 1st and have the ACO submit their budget and annual reporting to us by October 1st. The tentative dates for presentations are the ACO to present on October 17th, and then the board to present our analysis of their presentation and our review of the guidance on November 7th. We would open it up for public comment and then come back with a potential vote on November 28th to establish the ACO's budget and then the ACO would receive their written order from us in December, but we'll update you on that timeline if it does change. So the first section of the reporting requirements ask the ACO to provide an executive summary to us. We'd like to see what their differences and changes are between 2018 and 2019. So this may include providers who are joining or exiting the network, pilots of their programs with their successes or challenges, any changes in staffing or operational budget, and we realized last year that there were needed to be assumptions made where during their budget submission because some of their contracts are not finalized yet, so any assumptions that were made on the attributed lives and their per member per month payments that they'll be receiving from the payers. So this section is regarding the ACO's provider network, and we have several appendices that are also on our website for review. We did not include them in the printouts today, but we have one, what our first appendices is providers by type and really we're getting a snapshot of the contracted entities and independent providers that will be participating by health service area and the types of payer contracts that they will be participating in, whether those providers are new for 2019, so we thought we can do that comparison to determine who are additional to the network and also several population health questions that were interested in specific to one care, whether they have medication assisted treatment providers in their network and whether they're using care navigator. We also have a summary provider template that looks at specialists by health service area and types of primary care providers by health service area. So we have a new question this year which asks about scale and recruitment strategies over the next five years for one care to report on what their initiatives may be in the coming years. And then finally, we have a number of questions about provider contracting and their risk models and we've asked to see the provider participation and collaboration agreements and the levels of risk that are required between the ACO and provider in their health service area. This will help us for our actuary when we're evaluating the risk mitigation section and risk model of care. So then the next section turns to the ACO's participation with the payers and what those program arrangements are. So we will expect to receive information from one care on their 2019 development of any contractual agreements that they have with payers and we are also asking for their payer quality measures and analysis of that from the previous year. And then within the contracts, we will ask for the risk model by payer with the amount of risk and upside or downside gain that they're assuming and the risk adjustments, how they've built their per member per month by payer and any actuarial assumptions that were made and how their rates of growth align with the budget guidance that's in part two of this manual that Mike and Sarah will speak to. We also asked them how their payer contracts align with the all payer model ACO agreement and we asked them to describe how their contracts align and if there are any significant differences and possible rationale for that. Now I'm going to turn it over to Kelly to speak to the financial section. So for section four, the ACO financial plan, we've requested audit of financial statements and it's our understanding we should have the 2017 report in July for we've requested comparative financial statement templates this year. That's both a combination of what was asked for last year as well as what we needed to ask for after both submissions came in and that includes the balance sheet income statement and cash flow statement and it covers actual 17 budget and projected 2018 and budget 19. We're requesting they complete financial performance templates. These are all similar to last year's reporting and they are broken out in multiple ways. It covers revenues and expenses by alternative payment model categories and revenues and expenses by service, by care and line of business. We're requesting reporting for participating hospitals which is also the same as last year's request that was made post submission to the ACO. This is a breakdown of all pair model revenue and payments to and from participating hospitals by payer. This includes the maximum risk per participating hospital as well as the attributed lives by participating hospital. We're requesting again narratives related to budget spending. This includes but is not limited to industry benchmarks. They may have used to create their budget, methodology surrounding qualification and payment amounts for incentive payments, justification for the growth rates submitted, breakdown of delivery system reform dollars and the related goals, HIT spending strategy at both the ACO level and provider support, budget assumptions related to utilization and changes in provider network configuration and the impact on utilization. We've also requested a description of any changes to their funds flow. And for the risk section, we've requested again a risk mitigation plan for the ACO and all those taking risk as well as an actuarial opinion that risk arrangements do not threaten the solvency of the ACO and any additional documentation surrounding risk that the ACO may have. Stand. So section five is all about the ACO's quality population health model of care and community integration initiatives. So we have asked the one hair provider clinical priorities to us for 2018 and we've asked them for an evaluation on how they're doing in 2018 and what their projection is for 2019 and if those clinical priorities have changed and some of them, for example, are reducing admissions and emergency department utilization and increasing follow up after an emergency room discharge for substance use or mental health diagnoses. So we also then asked them for an evaluation of how they're doing on the ACO quality activities related to the out here model agreement, the 2021 agreement measures that are in the agreement. And both for 2018 and 2019 and we're interested if there are specific measures, outcomes and changes. We are also asking how one hair is tracking and capturing input from patients and providers and provider satisfaction as they're moving through this value based model. We've asked for a data analysis where they stratify their population into their four population health quadrants and how those total costs of care may differ by health service area. We have questions about the implementation of care navigator and also any care management activities and their growing capacity for substance use disorder treatment in the local health service areas. And then finally, we have financial tables in here on their community integration initiatives, which are the investments and incentives that Mike spoke to earlier. So we are interested in how they are investing in prevention, community based care and primary care. We did receive tables last year that total about $25 million with for member per month payments that they were making and also the blueprint and sash payments. So we expect those to show up here as well. But we're asking how they're doing in 2018 regarding those investments and any plan changes for 2019. So I'm going to, Michelle will speak specifically about how we're measuring primary care spending in section three. And now we're going back to Mike to talk about the budget that it's regarding the all-payer model agreement. So as I mentioned earlier, in deciding whether to modify or approve an ACO's budget, one of the things that you are to consider is the requirements of the all-payer ACO model agreement because that is part of the rule. That's going to be consideration. We didn't restate all those requirements from the agreement that I mentioned earlier. But we did decide to include basically the all-payer ACO model agreements parameters in terms of what you can do in establishing the benchmark for the 2019 Medicare ACO initiative. So specifically the all-payer ACO model agreement requires that the 2019 benchmark be established so that either one, the annual growth rate is at least 0.2 percentage points below projected annual growth from 2018 to 2019 for Medicare nationally. Or two, the compounded annualized growth rate is at least 0.1 percentage points below the projected compounded annualized growth rate from 2017 to 2019 for Medicare nationally. So that is what the agreement requires and Sarah Lindbergh is gonna explain what that means with numbers. Yeah, yeah, yeah, yeah, yeah. Thank you. Just one more to put that forward, please. Numbers. So please keep in mind that this is a limitation in the all-payer model agreement with the federal government and it's only talking about the Medicare portion. So the Medicare benchmark is a total spend that we're allowed and it's broken up into a few parts. One is for aged and disabled or otherwise people who don't have something called end stage renal disease and then there's a sub-component for those with end stage renal disease. So as you can see, the costs for those members are much higher but they're a very small portion of our population. So according to our 2017 numbers, 0.36% of Vermont, Medicare beneficiaries, traditional fee for service have that or in that aid category or in that bucket. And so therefore, when you look at another thing to keep in mind, there's so many moving parts but these are the values that are announced each April in the Medicare Advantage United States. Oh, what does the PCC stand for? Yeah, that's okay. Anyway, so basically this is the capitation rates that people who are bidding for Medicare Advantage are using in order to help price plans and so this is what they're projecting the costs for traditional non-Medicare Advantage fee for service rates to be PMPM, there we go. Annual projected national Medicare, total cost of care. Professionary, oh no, I'm sorry. Per capita, I should have guessed that, per capita fee for service projections. So per capita, these are the costs per member per month according to the most recent models. So in this past April, they said that they're expecting at the end of this year that it would have cost about $850 per member per month to take care of the age and disabled population and about $7,500 to take care of the end stage renal disease. And at this point, they're projecting those numbers to increase by 4% into 2019 for the non-ESRD or end stage renal disease and increased by 3.3% for the end stage renal disease. So therefore, according to the agreement, these are numbers that are important and we are restricted by that in order to set the growth rate for the Medicare portion of the benchmark. So when we blend those together, just a weighted calculation based on eligibility, we get 4% for the annual projected growth rate and 3.8% for the CAG or the compounded annual growth rate. So obviously we only have two years when the first year was set because we had the floor. So 1.37 is not anything that actually occurred. That was what the floor set up for us as the first term in that equation. So according to those values, we're, our ceiling, the most that we can do is either the 3.8 based on the annual growth rate or the 3.7 based on the compounded annual growth rate. You guys, this is gonna be embarrassing. Look at my equation. So as Mike mentioned earlier, there is a statutory criteria related to primary care investments in rule five. GMCB staff along with some stakeholders have identified a process by which we can monitor some ACO network spending on primary care services. And I probably won't say this enough but this will be a test year. It is a trial. We're still working out the kinks in some of this information. And at some point we would like to be able to evaluate this on a statewide level as well but we're starting with the ACO. So as you can see on this slide, we'll be looking at both claims and non-claim space spending in the ACO network. I don't need to walk you through the equation. It's much simpler than Sarah's. Just a note here that we've requested data at the all pair and pair specific level which could then also be broken down to a PMPM amount for those attributed clients. And again, test year. For this test year I should note too, we're requesting the ACO submit information for calendar year 2017 actual, calendar year 2018 projected and calendar year 2019 budget. And all of those terms should be right because Kelly taught me. This is just a very simplistic overview of what we're looking at. So the claims we're spending will be calculated using a subset of provider types and CPT codes as the numerator. That was identified through again some stakeholder processes and really building off of the SIM or group, the calculation that was done a few years ago. And if you recall, Rachel Block from Milbank had come to the board and presented on some of this data not too long ago. And she had also spoken with the primary care advisory group and brought some of this forward. For the non-claim space spending, again as Mike mentioned earlier, we were really looking at what we know the ACO has now and what we can build off of. And so this is not a comprehensive list of what will be included in that, but just as an example of things that we're looking at to include in that numerator and of course also in the denominator. But again, the numerator will be those payments that go to primary care. The rest of it will be the spending that's allocated throughout the network. So there's a note here that the provider types and CPT codes we can share. They're in the guidance. If folks are interested in seeing those, and again, we're still sort of working out what should and shouldn't be in there. And Sarah's team has been tremendously helpful in pointing out some places where we may have some gaps in that information. But with that, it's back to Melissa. She'll be in the water state. Thank you. Okay, so now we're back to the timeline for the public comment and vote for the budget guidance. And we'd love to open it up for any comments or questions from the board. So I'll start it off. One of the things that we continually hear from providers is how they chose to go in the field of medicine to actually provide quality care for their patients and spend time with the patients. And they feel like they have, in the old days we would say become paper pushers, but today's world we call keyboard pushers. And I know that we continually ask the ACO to provide us with what they are doing to reduce the administrative burden for providers. I'm wondering if we're asking ourselves if anything that we're asking is adding to the burden in an unnecessary factor. So are we taking a look at all our quality measures and making sure that they really make sense and that they can be reported in a way that doesn't increase the burden on the providers? So I wish Pat was here to speak about, oh, Michelle can speak about. So I attempt to speak to that. So we have the 2021 measures and all peer model agreement, but the ACO negotiates their payer level measures with their payer contracts. And so we don't necessarily have any control over what goes into those. But I think that there is a tremendous amount of alignment that we've seen in the years in this year's contracts at least. And so they're moving towards sort of reducing that burden. And I think, I mean, does that somewhat answer your question? I'm trying to make them as claims-based as possible so that the clinicians nor the ACO needs to go into the charts to do the chart review. That doesn't reduce the amount of data that needs to be entered, but that data would be going to the payers anyways for claims-based payments. As we move down the timeline over time, I think what a lot of providers are looking for is to make sure that this isn't just an additional administrative expense to the system. It's a coalition of the willing. And in order for it to succeed, the people that are part of that coalition have to be spreading the word to their peers and colleagues elsewhere that it's actually something that's benefiting their patients. And it is improving quality while at the same time controlling costs, moving people away from fee-for-service into a value-based system. And do we think that we have everything that we should have in the guidance to try to push that mission? I did add a new question in section five about provider satisfaction as they moved into the value-based model. We could reevaluate the question to determine if there's anything additional that we'd like to ask there to get more specific. I would also say as well, we're expecting a report at the end of June from the ACO on their new capitated pilot for primary care providers, independent primary care providers, which includes an evaluation of reduced administrative burden. That will help us determine what the first six months have looked like for this new value-based model. Great questions from the board. I would just respond to your question, Kevin, by also saying that I think as part of the 2019 guidance, there's a request for an evaluation of consistency across alignment across payers. And so I think that's another area where we can look to ask, is this increasing or reducing administrative burden? Because the more logical alignment, I should say, that we have there, I think it addresses some of the issues that you've raised. I did have one question, which is in the overall timeline for the process, are you thinking that we would receive information about the Medicare and other trend components on obviously the 17th from the ACO, but on the seventh from you all, and that we would concurrently vote on the Medicare trend at the same time as the overall budget, because we didn't do that point that way last year. So I just wanted to check about that piece. We're fine. We also agree that we'd like to align those timelines as much as possible. We're currently discussing when we would receive the data from Medicare. We are anticipating that we would have a preliminary number on November 7th to discuss with you. I would like to say that subject to change, because it so much is in our control, but we're working closely with our federal partners to ensure that we receive that information as sooner than last year. That's great, because of course, as we all know, Medicare sometimes thinks they can do something and then just like anybody else operationalizing if they sometimes run into snappes like last year. They're also working, because of our agreement in 2019 being the Modified ACO Initiative, they have some flexibility in how they receive the provider list and also review the provider list at the federal level, and they'll work on that through their provider agreement with the ACO. Thank you. So I would just note that we expect to have the final, so the preliminary numbers by the November 7th date and the finalized numbers within that 7th through 21st time period, I think on the earlier side in there somewhere. We are trying to adhere as closely as we can to setting the Medicare benchmark by December 1st or by 30 days before the calendar year starts. So I just have a question about some of the new statutory certification requirements. In a sense, I know this is recent language that was passed by the legislature this session, and now it's part of the certification requirements for the ACO, and I'm wondering, I think we as a board have to think about how we can evaluate whether the ACO has met the certification, additional certification requirements as I look at the language. For the first one, the ACO has to ensure equal access to appropriate mental health care. How do we evaluate that that is equal access, and how do we think about, in the second one, whether the ACO has received and distributed payments in a fair and equitable manner? What is fair and equitable, and how do we know that they've minimized differentials? And again, also, in the third one, how are we gonna evaluate whether the connections and incentives to address ACEs have been met? So I guess I'm throwing out to everybody here whether we should be putting guidance out there about some guardrails for how we think that that should be evaluated, or whether we should wait and see what they submit and then evaluate from there, so I don't know, but as I was looking at some of this language, I was thinking, this could be a challenge, and guardrails might be helpful to foreman, or whether this is also the first year it's in place, we've just received this language, so maybe seeing what the ACO submits and then evaluating it, so I don't have an answer, just throwing that out there for you all and then really to all of us to think about. I think that's a great point, Jess, because I think some of the language, it also makes it sound like that ACO is either the payer or the actual provider when they're not really either of those things, so I think that does make it a little more tricky. Yeah, and it's tricky language, so how do we evaluate that they've met this criteria? And can I just jump in, because Mike Barber and I spoke a little bit about this this morning, and to exactly your question, Jess, how will this look like? Look, how is it gonna play out at the board? We're gonna talk a little more, but we likely will have a recommendation from the staff to you guys, which you can then add to or provide input to from the staff, because if you're right, it just, I mean, we just got it a couple weeks ago, and now we need to evaluate whether they're adhering to all of these new changes, it is a big test. I would also say to complicate things a little bit, we also have the rule amendments that we are working on, and if we are going to put some standards around how we're gonna evaluate these things, it makes sense to put it in the rule, it doesn't mean it can't also be guidance for the ACO before that rule is finalized, which wouldn't be until February of next year at the earliest, so another piece of the puzzle, I guess, to think about. Okay, first time I'll open up to the public for comments or questions. Ken. Yes, thank you, I have to say, I think Jessica Holmes sort of captured the reaction that I had on the first two new statutory requirements. I underlined, you know, payments bearing equitable, and he would take, you know, the wise men and women of the world to easily handle that, I think. But I wanted to go back to the first one, which for a lot of different reasons, including that everybody has stated that our mental health system is in great disrepair, and it is, and under a lot of crisis. So when I look at this statement, I'm left with the feeling that a lot of this is just verbiage that isn't going to really get attention because it's significant in what it says, but the question really goes back to the Green Mountain Care Board. How might you relate to this question? You know, it mentions the Institute for Medicine, how many board members are aware of the history of the Institute for Medicine and its relationship to mental health and its reports and its relationship to parity and other issues. It is a specialty, so I just, I would throw out an idea that may not be popular, but it seems to me that it's, you know, given the assignment here, which is really an assignment to the Green Mountain Care Board, new models may be needed to at least explore, and it may be a mental health is a good one to use as an example. So I would just say if you read the language here in terms of a Green Mountain Care Board, it has to make sure or ensure the following criteria that the Green Mountain Care Board think about creating an independent panel that would be charged with the responsibility of helping frame those questions and come up with a conclusion. If not, we're gonna do what we always have done in healthcare. If you wanna know how things are going, you know, in our many parts of our healthcare system, you turn to the insurers and you say how are things going? That's how you get the information. And I think, again, I think, you know, to some degree, the questions are enormous and important and overwhelming, and the only ones that would have the information is the ACO. So, you know, you're kind of asking the ACO over a year's time to say how you're doing. And I don't think that's a good model. I don't think it's worth it at all. So anyway, it's just an idea to say, suppose that some kind of independent panel helped take those questions and also be charged with giving some assessment rather than having to be the ACO itself or state agencies which have a kind of a stake in this and it might help produce better answers and, you know, a group of well-meaning people who, you know, have a hard time getting arms around this one as well as some others. So that's the comment. I think it's an appropriate comment. It's something that I know causes me to lose sleep at night because I look at everything that we're tasked to do and all of it is legitimate. We should be doing those things, but then we have the competing interests of making the goals under the all-payer model. And they probably didn't intend to do this, but at least from my vantage point, at times I feel like we're being set up by the legislature to spin off some traditional costs that are in the human service budget rather than in the healthcare system budget. And if we assimilate those into the system, it makes our goal of reaching the targets under the all-payer model even harder. So, you know, you raise some huge points and some that there are no easy answers for. Other questions or comments? Dale. I know it all makes sense. I know just confirming what you just said, yeah, we have to have it this way. And what he just said. What I'm always looking for is I want to get this and to hide his presentation. This isn't an example. So I've got a clarity of what the ACO delivered.  Right now I can't do that. I just, it's a comment more of frustration. This is always high level. It's like that, what do they call that? The fourth arm of government, DFR would be an example. You don't see it, but they're extremely important. This is thing me a lot of times like that. And I just find that post for it. And I think there's a question in it. There is. I was gonna say if you'll kind of let me address that and just to pull a couple of the thoughts together, starting with your own on administrative burden. And what I would look at and certainly the alignment of measures is critical burden reduction initiative for sure. But also I look at that as in two ways. That's the accountable part of accountable care. We have metrics that we look at routinely become a learning health system based on the needs and the resources. And certainly Dale Heidi's presentation bears out that the measures we have have many areas that are, I don't see them as burdensome, but as opportunities for improvement. I think Ken's case in point, certainly for the integration of mental health, parity, both in delivery and payment, and just those opportunities to keep focusing the momentum of the system in the guardrails of those measures as priorities. So I don't know if that kind of answers what you're looking for. That's the clarity I try to bring forward and try to live every day. It goes there. Any other comments or questions? Yes, Tom. Thank you. My name's Tom Rees and I know a couple of you and the privilege of having spoken with you before and look forward to meeting the rest of the care warden. I'd like to come back round and address one of the issues that Ken raised. And I come to you wearing kind of three different hats. I'm a hospital CEO by training and experience. And I've spent the last 20 years of my career consulting with many hospitals that would help system organizations around the country on issues of clinical resource management and population health. So there's one hat. My local hat is that I'm the board president of N.F.I. Vermont, which is a provider of state-wide and acute adolescent care for mental health, where that's a younger population. And so I've had some fair amount of understanding of the current challenges that face the mental health system and I'm totally sympathetic with Ken's statement about how we're going to balance those and the tremendous challenge that presents to you. And the third hat I wear is a deep passion that I've spent the last five years exercising, learning about and that's broke out of my work at N.F.I. and that's the impact basis of having on the population of the city of Vermont and its families and children. And would like just to make two quick comments for you. The first is I bring to you a big appreciation for the work that this board does and the unbelievable challenge that you faced right now as you're trying to bridge the known, which is hospital budgets and what those look like and the total unknown in terms of what this thing called an ACL really should do, what it looks like and how it can even be observed in its functionality and we all in the state should be deeply, deeply respectful of the service you provide for us. The second is in exercising my passion for ACEs, I have joined together with five other members of the private sector as we are trying to organize the private sector to help the public sector and to help their sector deal with the issue of ACEs and I personally over the past 20 months, 24 months spent literally hundreds of hours in consultation and discussion with many in the private sector around the state. We formed an organization called Resilience Partners, Transformation Partners with the intention of actually focusing and energizing the rest of the population relative to this issue that in my estimation is costing us cash wise every year something in the neighborhood of 385 million dollars we're spending upon children who are suffering from ACEs and we can't afford not to do something about that and we need to do something about it now. So I would offer to you that as you look at certainly the ACE section of the responsibility that's been handed to you by the legislature, it's too early for you to really be able to put your arms around that, but it's there and it's a huge opportunity to screen out the care board to influence what happens in the evolution of our ability to manage ACEs in this community and the state. So I'm offering to you that I would be more than happy to share in college, to share our plans with you and to perhaps help understand how they interplay between all of those trying to deal with ACEs right now and the ACO might come together and would be more than happy to kind of step in the middle of that process and do what I can do to help from the private sector with your deliberation. Thank you, Tal. We appreciate that. I see another arm ballot back there. Is that you, Susan? Yes, I see that I'm offering the Vermont Developmental Disabilities Council, and this is more of a question for the board than for the presenters. I'm wondering, I've raised this issue of affordability of healthcare and whether or not the board is content. So my question is, is the board contemplating working into the budget process or to some other process, maybe, in a valuation whereby we would know whether or not people who are attributed to an ACO, Medicare ACO and commercial ACO in particular, whether or not being attributed is impacting the affordability of their healthcare compared to people who aren't attributed. Do they have more out-of-pocket expenditures? Do they have, are they paying more co-pays? We wouldn't expect to see much of a difference in the Medicaid ACO because Medicaid beneficiaries tend not to have co-pays and deductibles, but people in Medicare and people with who cross the shield do. And it just seems that we're gonna go another year, you know, we're in test year one and we'll be getting results. This week we'll be getting results from 2017. It'll be a while until we get the results from 2018, but it would be nice if at some point you guys build into the process requirements that part of the evaluation that looks at affordability considers what is the financial impact of being an attributed life.  Your only choice is to leave a provider that provider becomes a participant. But as an attributed life, we are basically generators of funds for the ACOs. They'll get a per member, per month payment for me whether I see a doctor or not, or how many services I use or not. But what is the impact on me if I am using it? And there's one thing in the budget criteria about the ACOs are supposed to report on their innovative spend. It's like, will we ever see if the people are actually getting those air conditioners or vacuum cleaners or mold-free mattresses, all the things of flexibility that an ACO is supposed to bring? So I'm wondering for the board when and how it'll be worked into the evaluation process to look at the affordability for individuals on their health care, the impact of being an attributed life or not. Especially since we're supposed to be gearing up to getting 90% of our monitors in in the next five years. So the question really relates to what the individuals out of pocket expenses are as far as co-pays or deductibles or what have you. And certainly one would think that as you move into a more value-based system that inherently you would tend to believe there would be less out of pocket, but that may or may not be the case. And I think that the only real way that we have to measure that, Susan, is through the public comment process where we actually hear from the monitors. And up to this point, I don't think we've heard from anyone that has told us they believe that their co-pays in the out of pocket are going up.  Even though they may be going to the same doctor in the same building, but all of a sudden they're paying more out of pocket. So I think that the doctors aren't going to be able to answer that question for us. And probably the ACO won't be able to either. It'll be actual for monitors who have to answer that question for us. I have a thought. And I don't know if we would have the data for this, but if there is evidence that emergency room utilization and those sorts of higher, those are areas where people tend to have higher co-pays. If that's going down and primary care is going up, there may be some way to sort of quantify it based on service usage, maybe not comprehensively, and certainly not on a per person basis. But that could give us potentially a little glimpse into that question. But again, I don't know that we have that sort of ability to do that with the data that we have available, but it's certainly something we can ask. Sarah? Yeah, part of me. For commercial and Medicare in particular, it's still pretty closely married to the fee-for-service architecture, meaning that claims are submitted as usual. So what will be, in Medicare's case, they will do 100% fee reduction for the paid amount in Medicare's portion, but we'll still have a record of the out-of-pocket amount. And for the commercial programs, it's going to be settled up at the end, so it'll look as usual. And also, so yeah, I agree while there might be differences in utilization as far as benefit structure and stuff, I don't think the ACO would have a whole lot of influence on that, so I'd be surprised to see the differences for the same sorts of services. But yeah, it's certainly something I think that Lynn can take a look at. If I may call, I think it's known that when people receive care coordination, they start using services, certain services at a higher rate, which does maybe result in better health for them, but it would also result in more co-pay. So instead of getting back surgery, maybe now you're going to go to physical therapy, you know, five times a month or whatever it is, physical therapy has a higher co-pay, it's a specialist service. So I really do think we shouldn't rely on anecdotal information from people who may or may not even know that they're an attributed life and might not know what that means to be an attributed life. If the data's available, and I'm sure the data should be available, it just seems to be that, as I always say, you value what you measure and if we're serious about affordability being a primary concern, affordability of healthcare for Vermonters, then we should be concerned about is this reform that we're putting in place, how is that impacting Vermonters actual, pocketbooks Vermonters actual, healthcare expenditure, and someone should figure out at what level we collect that data and compare it. Maybe it's the best thing. Maybe people on ACOs will have lower cost expenses and then don't clamor to be in and get their providers to join. But we don't know what we don't know until we measure it or collect it in any serious way and it seems like it would be you guys who would make that happen. And I think we'll go through another year of not knowing. So anyone can speculate. But me and Kim, we don't know. Well, I think Sarah's taken the charge to try to figure out a way to analyze this. So we'll see what she comes up with. Stay tuned. What's that? Stay tuned. I hope that's a charge. I think that would be awesome. Walter. Thanks, I appreciate it. Just wanted to follow up on Susan's and she's made some great points, but I think we all should remember that co-pays and deductibles are designed to restrict access to healthcare and increased profits. And if we don't put that out in the open, that's what they're designed to do. And when you talk about affordability, no one can afford to co-pays and deductibles. Frankly, I don't see the ACO reducing those. They might reduce premium, but they're not going to reduce their co-pays and deductibles for that reason. At least I see it now, but I could be wrong, but I don't see them reducing that. Well, they can't. They really can't because of the co-pays and deductibles are killing them. Yeah, but you're right. You're right about the premium is where it would impact it because the deductible in the co-pays is still the payers. And I'm not going to say that I agree with this position, but I'm sure you've heard the same argument from some of the providers that that's not what the co-pays are for. It's to invest the patient in their care so that they are concerned about the outcomes and are a willing partner trying to improve their health status. Actually, I heard that before. Not only raised it, but I heard the same generic comment before and I think that's part of this opinion on it. I hear it repeatedly from doctors that say if patients aren't invested, they're not going to follow the proper rehab and everything else. So, yeah, clarification question only on, but this involves Sue because it's the same topic. During the legislative session, I think, I know it did. I asked this question, but I think she was there and that's why I say she was part of the conversation. They did say the ACO is not going to reduce the co-pays, but they admitted to there can be an accumulative effect as they integrate the services, you can end up with more co-pays which does bring up an affordability issue of that accumulation of the co-pays and that's where the conversation ended. Nobody knew what that impact was going to be. So just using Sue's example for a minute, I think if you look at, so if you have, in this case, if you are referred to physical therapy and physical therapy resolves your issue in lieu of surgery with whatever outcome, you will have more physical therapy co-pays which will add up to a certain amount, but you will not have the surgery co-insurance or co-pay depending on your plan design that you would have paid with surgery. So I think it is something that's harder to measure because it's going to be a person-by-person condition-specific issue, which is why I was saying maybe we could look at what the overall trends are in care utilization and see if there's an aggregate way to get a handle on that because we're not gonna be able to look at each and every single individual to see, to make that comparison of an individual, basically, we just don't have a staff like that. But I think we could try to look at trends and see how that could be in the aggregate effecting co-pays. So I think what I'm hearing us say is we think it's an interesting issue. It's not simple and we do have limited staff capacity in data analytics and we have a lot on our plate in data analytics, including required federal reporting, but we're gonna look into it and see if we can figure something out. It may not be for this year, it may take longer, I don't know, but I have full confidence that if anybody can figure out our data team can. I have full confidence, too. I guess I would just also encourage folks to... No pressure, Sarah. I guess I would also encourage folks, people to realize that we have to take a long view here in the sense that really what we're trying to do is allocate resources towards primary care, towards preventative care, and that is a complete system transformation and that's gonna take time to show the return on that investment. And so to the extent that we allocate more money to preventative care, primary care now, we might not see the returns on that investment until five years from now. And people are not going to emergency rooms for 20 years or whatever it is. And to Tom's point about investing in ACEs and things like that, these are upfront investments that may cost more now but are gonna have longer term effects. And I just wanna encourage everybody to realize that we may not be able to quantify the short run gains, but we have to have that long view. Any other questions or comments? Seeing none, that was a lively exchange of thoughts. And I wanna thank the panel because each of you are working very, very hard to try to make this a reality. So thank you for everything that you do for your time today. Is there any old business to come before the board? Seeing none, is there any new business to come before the board? Seeing none, is there a motion to adjourn? Second. So we moved in second to adjourn. All those in favor signify by saying aye. Aye. Any opposed? Thank you everyone, have a great day.