Good afternoon and welcome to the Green Mountain Care Board. My name is Kevin Mullin chair of the board and we're about to get started. We're going to start with the minutes of Wednesday November 18th. Is there a motion. Is there a motion. Second. It's been moved and seconded to approve the minutes of Wednesday November 18th without any additions deletions or corrections. Is there any discussion. Hearing none. All those in favor of the motion signify by saying aye. Aye. Those opposed signify by saying nay. Let the record show the motion carried unanimously. At this point we're going to turn to the executive director's report. Susan Barrett. Thank you Mr. Chair. I have a couple of announcements. I first wanted to start with our schedule for December that is posted on our website. And I just want to give you an overview because it is a pretty busy month and there's just a couple of meetings that I want to make sure the public hears about. First next Tuesday December 1st. I cannot believe it's December already. We are going to have our first meeting of the prescription drug technical advisory group and that takes place from 11 to 1. And that is open to the public and you can join the the instructions for joining the meeting are on our press release. In addition on Tuesday December 1st we have a data governance council meeting from 2 to 3.30. Also open to the public. Instructions are on our website. On Wednesday December 2nd we are having a full day of board meetings. So we're going to start at 10 a.m. with a morning board meeting and we're going to continue the discussion on the FY 21 hospital budget debrief. And then we'll come back in the afternoon starting at 1 p.m. And on our agenda that afternoon we'll have the 2020 update to the health information the 2018 to 2022 health information exchange strategic plan with a potential vote. And then we'll also have a 2019 ACO financial results panel and last we'll have an all-payer model update from our staff. And then on Wednesday December 9th in the afternoon only that day at 1 p.m. we will have the ACO oversight FY 21 staff analysis and preliminary recommendations on their budget. And then on Wednesday December 9th the same day in the evening we from 5 to 7 we're convening our primary care advisory group again open to the public and the information is on our website. The next week Wednesday December 16th we have a panel discussion on provider reimbursement in Vermont and that starts at 1 p.m. And then the next week two days before Christmas we have Wednesday December 23rd the accountable care organization oversight FY 21 ACO budget potential vote. Right now we don't have anything scheduled on Wednesday December 30th but with activities around the ACO budget benchmark all things finishing up the end of the year we may have additional agenda items which will be posted appropriately. So when you have a chance take a look at that schedule again on our website. And I did want to just make a few remarks before we turn it over to our partners at AHS who are going to be presenting to us today. I want to thank them for coming in and sharing the all peer model ACO model agreement implementation improvement plan report. So we were really looking forward to hearing this update from Secretary Smith and Director of Healthcare Reform for AHS in Abacus. As background I wanted to let the board know and the public know that this plan was developed in consultation with the Green Mountain Care Board staff. While the feedback from the board staff incorporated the into this report generally mirrors views expressed historically by the board the regulatory strategies included in the report have not yet been discussed in a public meeting and that's why we're here today. So the purpose of the discussion today is to receive the overview of the plan from our partners at AHS and for the board to discuss the regulatory strategies specifically. I mean we could we're going to talk about the whole report but specifically around the regulatory strategies at our public meeting today. Staff and I will continue to analyze these recommendations and we'll seek your opinion as an independent board on how these may be implemented in the future. And it's likely that the staff and you will continue these discussions at future board meetings. I also want to note that Elena Barabe who's the Director of Health Systems Policy will be she's on the line and will be available too if there are questions regarding specific GMCB activities that our AHS partners obviously may not have an answer to. But I'll turn it back to you Mr. Chair and I want to wish everybody happy Thanksgiving tomorrow too before I forget. So thank you Susan. I'm trying to do a little soft shoot here. But Ina let me ask you a question. I understand the Secretary has been delayed. Can you proceed without him or how should we handle this. I believe he's here. Mr. Chair Maven actually here. Oh good. I knew that if people wanted me to sing and dance we were in trouble. I could have done a tap dance too Kevin. I I I do know the soft show so. He said he said beam me down Scotty and there he was. So I'm not sure which of you is going to lead it off but whenever you're ready proceed. Well thank you Mr. Chair and thank you for having both Ina and I here today as you know after the federal government issued a warning letter because Vermont fell short of its scale targets for two consecutive years in its all-payer model. I asked Ina back as a team at AHS to really take a critical look at the all-payer model and produce a report with findings and recommendations about where we are in the model and what actions do we need to take to do in order to move forward in the model and what Ina and her team produced I think can be aptly described as a blunt outlook of faults and issues and what we need to do to change for the model to be successful. And I appreciate all the work that Ina and her team did in bringing this report together. I really believe this is something this is a blueprint to to success and and how we looked at this is in four sort of separate buckets. We looked at it from what do our federal partners have to do or change to make the model successful. An example would be to treat Medicare as a true perspective payment system. It's not right now. What do we have to do at AHS to make the model successful. And frankly we need to make major organizational changes to align the various health care reform efforts and operations here at the agency. I'm looking out the window it's an empty building. I'm sitting in an empty building but I'm looking out the window here. We we have to make changes here because we're fairly dispersed in in our efforts in our reform efforts here within the agency and then externally what does the ACO one care have to do and we're recommending a new leadership perspective with the ACO and then what does the Green Mountain Care Board need to do and how do you align those to make sure the model is successful as we we go down this path together. Mr. Secretary can I just stop you for one second. I did get a text from someone saying that there's a bad echo. I'm not receiving it here but if anybody is on the line and is not muted if they could mute themselves that would be greatly appreciated. Sorry about that Mike. No that's OK. So why are we doing it and and there are three reasons that come to my mind why we're doing this. I've seen the advantage of the value based payment system. It gave us and I've said this before before the board it gave us tremendous flexibility and provided stability within the health care system when the first wave of the pandemic I used to say the height of the pandemic now I have to say the first wave of the pandemic came through and it really rocked us. It really rocked the health care system and we were able to move money in order to stabilize operations throughout the health care system. We wouldn't have been able to do that without the value based payment system that we we have at our disposal mostly Medicaid money right at the moment. Fixed fee you know a fixed fee system provides incentives and drives costs that are sort of perverse to what we're trying to do which is cost containment and enhanced quality. And I've said a lot on that in various forms but I truly believe value based system is the way to go. I make no bones about that as I look to the future. And then this system that we have now needs active engagement to get it on the right path. I just didn't believe we were on the right path. I didn't believe we were engaged enough to put it on the right path. I didn't believe we had all our sort of focus on what can be done to put this on the right path. And I think the active engagement is important on this and and I've committed to be actively engaged in this process both with the report and moving forward. I mean the report is the easy part frankly. The harder part is going to be implementing all the all the recommendations that are in the report. So with that sort of introduction I'll turn this presentation over to Ina to go through the specifics of what's in in the report. So Ina take it away please. Thank you Secretary Smith. Abigail would. Is that what background by the way that I'm hearing. Hopefully not too much. Abigail would you like me to share slides from my platform or would you like to share the slides that I've provided. It'd be easier if you could do that Ina but if you need me to I'm available. I will initiate that now. And I do want to thank Executive Director Susan Barrett and her staff for the many hours of work spent as she mentioned collaborating and consulting with us as we were putting together this report. That consultation as a co-signatory so to speak certainly strengthened this work and is is incredibly important as as Secretary Smith mentioned the work now is ahead of us in implementing these recommendations and we wanted to certainly be sure that that we worked with you where applicable on the recommendations. As as was described recommendations for improving our performance in the all-parent model agreement are divided into four key areas which include thinking about and using and maximizing our federal-state partnership to achieve the ends of of success in this agreement. Reorganizing and prioritizing the all-payer program within AHS some recommendations for the Green Mountain care boards that we think are consistent with the recommendations that are put forward in this report about the leadership perspective at the ACO and the focus that we believe is necessary on the core business of the accountable care organization in identifying areas for efficiency in the health care system as well as quality improvement. With respect to the federal-state partnership we've identified six key recommendations and strategies to move progress in this agreement and to position us potentially for success in another potential agreement. First we believe that the scale targets should be looked at again with CMS in order that we have a good discussion about how those targets can reflect the realistic capacity for participation in this model in our state. As you're familiar the denominator that is currently in place for these scale targets captures a number of Vermonters or holds us accountable for Vermonters to be attributed to the model who are not able to be attributed to the model who cannot be attributed based on the attribution mechanism. We also recommend and this is a recommendation consistent with work that has already taken place today that the Medicare risk corridors be reduced to decrease the financial burden of participation for hospitals and as has been discussed by this board in public meetings this this approach is important particularly given the financial impact of the pandemic and is important for garnering additional participation in the model among hospitals today. We'd also like to reckon we also recommend that we request CMS to work with us the state of Vermont to establish written guidance and best practices with respect to the critical access hospitals. As you are also familiar the critical hospital critical access hospitals cost reporting requirements are based in the fee for service system and therefore need to be considered differently when critical access hospitals are participating in value-based payment models. We also want to establish a path for the Medicare payment model to mirror the Vermont Medicaid next generation fixed perspective payment. This is really the premise of the value-based payment reform that we are trying to achieve in Vermont to move aggressively away from fee for service reimbursement and to provide predictable fixed and sufficient payments to participating providers and Medicare should be aligned in this approach and we'd like to accelerate that work with CMS. Further we want to ensure that the Medicare 2021 benchmark can provide as much stability and predictability as possible despite the ongoing uncertainty that's associated with the global health pandemic and we we want to collaborate with CMMI to encourage the health resources and services administration commonly called HRSA to prioritize value-based payment for federally qualified health centers. The Agency of Human Services is going to prioritize this model and accelerating participation by conducting education and outreach to non-participating self-funded groups about the benefits of participating in value-based payment models and this includes the state and health health employee plan members. However these the final decision has been made that the state employee health plan member members will be attributed to OneCare Vermont in in 2021. We also want to prioritize the integration of claims and clinical data in health information exchange and this is one of the components that Secretary Smith referred to when he he spoke about the reorganization within the Agency of Human Services around the goals of health care reform. We we are reorganizing some key programs in the Agency of Human Services which all have a focus on health care reform and certainly can accelerate progress in the all-payer model bringing them together very specifically with the goals of of enhancing our progress in our all-payer model agreement is is one of our strategies for improving health information exchange is and the information available through it is a backbone for health care reform for providers who need data and information to inform care and decision making and claims and clinical data if integrated can can be an even stronger resource in this aspect. So we are proposing to bring together the HIE as well as the Patient-Centered Medical Home Program the Blueprint for Health along with the Vermont Chronic Care Initiative which provides for currently outreach and engagement of those Vermonters who are attributed to One Care Vermont and yet do not have primary care providers. The VCCI program is working with One Care Vermont and and is is helping Vermonters who do not have a primary care provider to identify one bringing all of these functions together within the Office of Health Care Reform at the Agency of Human Services is one of our key initiatives to accelerate progress and to ensure that we are working in alignment and in the complementary function with One Care Vermont. We also want to partner with One Care as well as the delivery system users to evaluate the efficacy of the Care Navigator platform. As you are familiar there is mixed there's a mixed assessment of Care Navigator as a helpful tool in in coordinating care. We the the Care Coordination Tool is certainly central to improved coordination improved experience of care a seamless experience of care for four Vermonters attributed to the ACO and we want to be sure that the platform for care coordination is the best available tool. We also in the spirit as I just described of aligning the patient centered medical home work as much as possible with our our emphasis on value-based payments we would like to take a phased approach to condition participation in Blueprint for Health PCMH payments on participation in value-based payment arrangements within ACO. Further we are recommending that AHS One Care Vermont and community and community-based providers work together to improve collaboration and strengthen integrated primary specialty and community-based care models for people with complex medical needs and medical and social needs. And again organizing our efforts with the Vermont Chronic Care Initiative and the Blueprint for Health together in alignment with health care reform and under the goals of the Alpera model agreement is a strategy that we've identified to improve in this area. AHS and One Care Vermont along with community provider partners should identify a timeline and milestones for incorporating social determinants of health screening into the standard of care for health and human services settings. And this recommendation as you are familiar is speaking to the population health outcomes targets in particular in our agreement that seek to reduce deaths due to drug overdose and suicide. AHS through the Blueprint for Health will also jointly explore with One Care and stakeholders the best available tools for capturing real-time patient feedback and to pilot this methodology or identified methodologies with willing primary care practices. This recommendation is in the spirit of capturing real-time feedback from from Vermonters particularly because we are in a system that is in transition and a system that is focused on transformation and it's important to understand the impact of those efforts in real-time. And finally in this category of recommendations AHS and the Green Mountain Care Board working together will prioritize more regular stakeholder engagement opportunities to share progress on the agreement implementation and to and to hear from from stakeholders. In the category of recommendations that are really focused on the regulation of the accountable care organization and ascertaining progress in this agreement we're we're recommending that the Green Mountain Care Board and and AHS request that Blue Cross Blue Shield Vermont MVP and One Care Vermont identify clear milestones for including fixed prospective payments in contract model design. Further we recommend that under the authorities of ACO and hospital budgets that the board should explore how ACO participants can move incrementally towards value-based incentives with the providers that they employ so that the models for for provider payment within the organizations that contract with the ACO reflect the the value-based contract terms that that organization has with the ACO. And finally annually in its in its budget presentation to the board we recommend that One Care should identify cost growth drivers across its network and detail its approaches to curb spending growth relative to the cost growth drivers that are identified and also identify its approaches to improving quality. The final category of recommendations speaks to the leadership perspective at the accountable care organization consistent with other recommendations that you've heard. We recommend that One Care elevate data as a value added product for its network participants and support providers in leveraging this information for change. And this this recommendation relates to a series of other recommendations in section two again that of our report again that are focused on strengthening the ACO leadership strategy. We'd like to recommend a focus on entrepreneurship and and in that focus understand how the ACO can ease providers transition to value-based payment and delivery system redesign. Again as I've said we we want and we are recommending that the ACO identify and perfect its core business. We recommend that the ACO relative to recommendation 13 provide useful actionable information and tools to participating providers and improve how it packages information for providers. We recommend fostering a culture of continuous improvement innovation and learning through this focus on on data through identifying systems for improvement where data indicates need for improvement and through tracking of results against the targets for improvement. And finally we recommend that transparency and responsiveness to partner requests for information be be held at the highest standard and that we would expect some improvement in transparency and responsiveness to request for information. And that those conclude these are a summary of the recommendations in the report. I know that you have the report and I certainly invite a reading of the report in full as these summary recommendations are intended to be brief in nature and and certainly do not have all of the background associated with them. Thank you. Appreciate your presentation here. Kevin Mr. Chair we're we're here at your pleasure. You're muted. Probably the most sense I made all day. Thank you Mr. Secretary and on behalf of the board I want to thank you for your leadership on this and you know ever since I stepped into the role as chair of this board I've had different providers say to me things like well we're not convinced the state of Vermont is fully behind the all-payer model and I said well what are you talking about it it was signed by the state of Vermont it is the state of Vermont's agreement and and I've heard the governor on a number of occasions mentioned the work of the model but clearly I think a number of providers around the state were seeking more in the form of leadership from state government and you have provided that so thank you. I'm going to open it up to the board for any questions or feedback to the secretary or to Ina and I guess I'll go in alphabetical order starting with Jessica. Okay great well thank you very much can everybody hear me. We can. So thank you for all the hard work on this report. You know it's clear we're at a critical juncture here as we you know are approaching the end of this agreement and there's plenty of time left I think to build on successes and overcome weaknesses and especially as we're thinking about another agreement with CMS so there's lots to learn and build on. I have some questions on some of the recommendations so let me talk through them. Recommendation 2 proposed a reduction in the Medicare risk corridor which I know we've already implemented for 2021 and there was a clear need for that for carrots to entice more providers into Medicare lowering the risk made sense with COVID and the financial vulnerability of hospitals I'm wondering your views on kind of beyond 2021 is a one and a half percent or even a two percent risk corridor across the whole system enough to incentivize the types of changes that we hope to see in the delivery system. And related to that should the risk corridor in your mind be the same across all hospitals or you know should hospitals that are largely referring you know out for costly care by the same risk as hospitals that are delivering that higher cost care. So how do you think about you know going forward recommendations around the risk corridor and the distribution of that risk within the system. You know let me thank you let me take the first part of that question about the risk corridor and then I'll give enough time for you to think about the second part of the question on this but the first part of the question is no we've got to expand the risk corridor at certain points I think it's going to be incrementally that we expand the risk corridor at certain points but yeah we you know you got to have skin in the game. Now this is an exceptional year as everybody knows and and I think you know we have to make sure that people understand and get comfortable with the model and I think you know bringing the risk corridor down to allow people to enter the the all-payer model in a way that they feel comfortable with I think is important but I think eventually as people get more comfortable with accepting risks taking risks have the tools to manage their risk I think you know we need to talk about expanding the risk corridor as we move on you know do you want to take the second part of their question which is do you see different sort of differential within the risk corridor. I think it gets a little messy but I'll leave it to Ina to explain. I agree that we do want to see the risk move incrementally and that we are in an exceptional time now and I also think to your question board member homes that the ACO has arrived at the delegated risk strategy the delegated risk strategy is not one that is prescribed in the agreement and that that gives some flexibility for the ACO to consider how to delegate risk in the future particularly as more experiences gained in participation and as a different complement of providers begin participating in the program we hope. We hope to see some more participation particularly in Medicare and I think it is fair it is it is fair to acknowledge that as providers begin participating they have different degrees of experience with risk. Yeah and I just I want to expand on that because I think it's important not everybody's created equal and so I think you have and this is part of the entrepreneurship we were talking about how you how you innovate how your entrepreneurship in trying to find out your customer base and what it needs in order to be successful and I think you know that you brought up a question you brought up the second part of your question that I think is important you know what what does the ACO need out there from their customers in order to make you know that this work and I think you know not all not all risk is equal as we as we look at this. Well so on a related note I think one of the biggest customers potentially of one Kvermont is Dartmouth Hitchcock. It's a founder it's the tertiary care center of choice for many Vermont residents on the eastern part of the state. So what in your vision what is you know should there be an enhanced role of Dartmouth Hitchcock in Vermont's health care reform. How do we entice Dartmouth Hitchcock to be all in. What is the role in the kind of implementation in the next few years of Dartmouth Hitchcock if you're able to share any insights there. Board member Holmes you led me right down the road on this didn't you you set your questions up that led me right into that. Let me we need Dartmouth to participate. I think it's important that Dartmouth you know we all know right now that Dartmouth isn't there. They're a founder of the ACO but in many respects they aren't participating in the value based payments that that I envision. They certainly aren't Medicare they certainly aren't a Medicaid and and I would like to see them participate in the all-payer in the all-payer model in a way where I'm trying to drive it which is the value based payment. I just I I said this in the press conference I don't think it's a matter of if a value based payment is coming it's when it's coming and and I think you see it on the federal level whether it's the Trump administration or even the Biden administration I think you see that value based payment is coming down down the road and for good reasons you know I mentioned a couple of good reasons during my intro but I think we need to entice Dartmouth to become more active in sort of the value based methodology that we're requiring that we're we're advocating for all Vermont hospitals and so I don't know if I answered your question. Well it's a tough one I mean it's a tough question how do we entice them but I guess maybe to the degree that we're expecting some entrepreneurial innovation from the ACL maybe there are some creative strategies that you deployed there but I do think it's a it's a notable absence given you know their founding role and the importance in terms of tertiary care which is high cost care typically right so I agree one of the findings related to low participation in the self-funded market and SIGNA was mentioned as a pair with substantial number of contracts in the state and I I wondered I noticed some of the tactics that fell under recreation recommendation seven there wasn't really a recommendation around working directly with payers like SIGNA you know and I understand their federal limitations on ERISA plans and all of that but I wonder are there any tools in DFR's toolkit to entice payers like SIGNA to participate in health reform efforts or any other carrots the state might offer directly working with some of those payers who are basically you know administering those self-funded plans what else can we do there I guess directly with the payers or the administrators I should say. Yeah the the the gist of some of the recommendations in terms of expanding participation among the payers and in particular and an attribution to the to the model is something that I think is important and we had it in in we need to find ways to sit down with those payers to figure out what they um what we can do in order to to entice them into the model because you know we can we can sort of Medicaid's almost all in so it was with the value base I'd like to get Medicare in but we we don't we don't make this model successful unless we get the commercials in and that is that is one of the things that you know we plan and one of the recommendations was I have to sit down with them and figure that out Blue Cross Blue Shield MVP sit you know all the all of them in terms of who they who they are so I'm planning to do that to sit down talk to them wonder what some of the hurdles are for them in order to participate and see if we can get them into this all-payer model I think it's important and you know if I have if Mike P check has to be right with me um to do that that's fine too okay um I had a question about uh recommendation nine this was around we should the Green Mountain Care Board should explore how ACO participants can move incrementally towards value based incentives for the providers they employ so we don't typically regulate employee contracts I'm just curious what if you could you know share with me a little bit more about your vision about how we might move incrementally towards uh you know regulating in that way if that's what you're thinking I mean we don't typically get involved in employer employee contracts so just curious as to what your vision was there yeah you know you want to start out with that and then I'll finish up with that sure I I think the vision is is to is is really based in the principle that if providers do not have incentives that are aligned with the value-based model that the the delivery system transformation is not going to be um isn't it it perhaps won't be followed through on that you really amplify the transformation when the provider incentives are aligned with the goals and with and with the value-based model so for instance I think one of the things that we consider to be an incentive that would be aligned with value-based payment would be um uh uh a reward for performance in in quality for instance rather than um there being bonuses for um not rather than I excuse me bonuses for quality performance in addition um to other other terms I don't think that we have a vision for um exactly how that happens but we think it's an important conversation to have and because the board does have authority over both hospital budgets and ACO um that is that is why we we recommended that the board consider this um this area so um that's where we're coming from really our providers being paid in a way that supports the goals of the value-based model and the goals are if the goals are quality improvement which they absolutely are providers being rewarded when they achieve high quality outcomes in this model okay um I think my second to last question is Kevin just let you know um recommendation 14 proposed conditioning the blueprint payments on participation in the ACO I'm just wondering if you had any sense of how many additional practices or attributed lives that might add to the model in terms of having a scale impact if there was that conditioning we need we need to do that analysis in terms of scale impact I think the the other the other piece of it well there there could be an impact on scale I think it's also important that this recommendation really reflects that we have our healthcare reform priorities aligned um and that if we are we're we have a strong patient-centered medical home program that program doesn't include risk if we think that risk and skin in the game is important for performance in value-based payment model then do we want then then the idea behind this recommendation is that the patient-centered medical home program is something to participate in so as as long as uh you are also participating in the value-based payment model and I just want to make sure everybody understand we're going to phase this if we if we implement this we're going to phase it slowly in this is not going to be an overnight thing yeah this is a longer term recommendation this recommendation is is um primarily in the service of the financial performance on the financial targets um as well all right um and I guess my last question it was it's more of a thought but a question um is embedded in it I totally agree with the two overarching principles we need to increase scale and we need to move more revenue into fixed perspective payment um but obviously that's going to take a little bit of time and I'm just wondering has AHS considered undertaking a study on low value care in the state right this is the care that provides little or no benefit to patients has potential to cause harm adds waste to an already resource constrained system there are widely accepted lists of surgeries and diagnostic tests that fall into this category and it would be really helpful to know where it's happening how often it's happening by whom and what it costs us and my thought I guess was uh you know diva has the incentive as a primary payer to want to know where all this low value care might be if it does exist and the department of health has this medical expertise with dr levine at the helm who's done such a phenomenal job and has such wonderful expertise I wondered whether AHS might be uniquely positioned to use claims data to use medical evidence to identify areas in the state where we are seeing low value care um there was a study in Virginia that looked at 44 low value services in their using their all payer claims database they found 600 million dollars in unnecessary services and added costs so just wondered whether this might be a way to expedite you know our health reform efforts right a study in Vermont could shine lights on areas where the delivery reform system or delivery reform change could have the greatest impact and work simultaneously as we're trying to add scale and trying to shift more payments actually targeting those areas where we're seeing low value care just wondered if that was anything that had been considered given some of the the expertise at AHS and some of the incentives by being a payer it it wasn't considered because we we didn't look at we're looking precisely at the all payer model but it is something you just sparked my interest in uh so let's let's take that if you like if that would be helpful the Virginia study but yeah let me um let us think about that that's not that's not something I um want to dismiss at all so great well thank you so much for all of the hard work here and I look forward to you know improving upon what we've already built great thank you thanks Jess Robin thanks um thank you very much for the presentation uh and I appreciate um you being here today to answer our questions um so on the recommendation for related to establishing a path to move Medicare payment to uh a fix a different type of fixed perspective payment I was glad to see um the concept of developing really the modeling that we would need to get there um because my assumption was given the short time frame you had to put together the report that you probably have not done modeling on um some of the unique features of Medicare that may make um sense to have some differences from the Medicaid payment methodology um I do think it's an area we should should explore because I I think that there's a lot of confusion in the provider community right now about the fixed perspective payments in Medicare and how those do or do not relate to the benchmark um so I think one of the lessons learned from the previous negotiation is um trying to really model some of those changes and get provider feedback in advance of implementation and I think you know we tried to do that before in the first negotiation but um it's certainly I think working very differently that we had kind of envisioned at that time um so I think it is important to try and educate providers uh as part of this path so that they have an understanding of how the current model works as well because there really is is no connection between what they get paid in their fixed perspective payment and the benchmark that we set in terms of the data etc so um I just wanted to make that comment really more for for us to uh think about uh both the board to think about and of course in partnership with you uh in terms of what that path might look like um in terms of the Medicare benchmark in 2021 and the stability and predictability I totally agree I think that's something that our staff has been working on um I also think that we're probably going to have to look for that in 2022 because 2022 would be informed by 2020 data which we know is problematic so um I do think that may be more of a two-year endeavor uh because of the data sources um in terms of so I'm going to switch to I just wanted to make those couple comments on those issues um I wanted to my question next question is really around the recommendation 11 around the claims and clinical data integration in the HIE um the timing seems a little disconnected with what's in the HIE plan um just to be frank so that may be something that we want to try and true up in the next week before we vote on it um the because the HIE plan calls for starting with a Medicaid pilot which I think is is consistent with the timing that you've you're short to medium term timing that you've indicated in the report but um I think as we all know Medicaid claims data is very different than commercial and Medicare claims data so um so I just wanted to bring that up in terms of were you thinking in terms of your timing to accelerate that more quickly beyond just the Medicaid pilot I was okay yeah great so that would be um great to connect to Emily Richards on Ina so that we can try and true that up before we vote on it um I did have a bunch of questions for Emily around the claims and clinical data in terms of how that interfaces with B-cures but I know that our staff Sarah Lindbergh is going to be participating in that work so um I do think at some point we're going to have to do a deeper dive around that because I would like to understand how it connects with B-cures and make sure we are not creating redundancies and that kind of thing um in terms of the data and information um certainly I agree we've heard very mixed reviews around care navigator in terms of for example the Brattleboro community seems to love it everybody in Brattleboro like their comments in rural health services task force was hey why isn't everybody using this why isn't AHS using this why isn't you know the homeless shelter everybody so I do think figuring out whether it's the right tool in doing some sort of evaluation if that makes sense but I don't think that just the tool itself is the only component in terms of provider satisfaction so I was wondering what your thoughts were around not just looking at the tool but the implementation of the tool in the community. Ina do you want to take that? I think that's a good recommendation Robin I think that there's there is the tool itself and then there's also um who can and in in our recommendation I think we were thinking about evaluating the tool and and really looking at who and how the tool is being used now the use cases for it and what's missing from that so I think um you're providing some additional context but it's it's absolutely in line with what we were thinking and and and I appreciate you explaining that piece at this time that is certainly what we're thinking and I think we'd like to be we'd like to see an expanded portfolio of users for a care navigator for instance so in a particular community where there is there's an identified need for more of the care continuum to be able to use that platform how can that how can we um see that uh to reality so yes that's that's absolutely in the spirit of what we're considering with this evaluation. Great because that um uh if it's not the right tool then it makes sense to identify that sooner than later but it it was quite a mammoth undertaking to get it rolled out so I do think it could cause a hiccup to re-roll out a tool statewide so I think that needs to be sort of in in the thinking too is not just like yes or no right tool but how do we make sure we don't disrupt ourselves or if we do think we should switch gears when is the right time to do that because it will be a several months retraining and re-roll out which uh will obviously have impacts on people's work and uh the results um in terms of the blueprint recommendation have I was curious and I didn't look it up whether that requires statutory change. The the recommend um are you speaking which recommendation are you speaking about related to the blueprint? To condition the payments to participation in the ACO. This is a longer term recommendation as we indicated and it's one that we have to spend some time exploring and that's a piece that we will be looking into. Okay um I that sounds great I was just curious about that and um of course it's uh the blueprint payments are also required to be paid by the the commercial payers as well so um I assume that's a area that you still need to look into in terms of talking to them about the feasibility of that recommendation etc okay um the only last thing I will say is that uh at least with the Medicare dollars I think as Ina knows that was not the expectation um for the use of those dollars so I do think I'm glad it's a longer term recommendation because I think there's a lot of exploration that needs to happen including on the total cost of care because if you have people dropping out of the blueprint for example which is obviously not the goal the goal would be to have people remain in the blueprint and move to the ACO as well but if you had some provider retraction those savings from the blueprint participation are helping us in the total cost of care even if those members are not in the ACO so I do think it's a more complicated cost analysis okay I think I'm coming to a close um so um again on the commercial best touched on this in terms of the commercial payer participation um I do think in I'm all for having more explicit milestones in terms of FPP development it's something that um one of us usually asks both the carriers and the ACO about during our regulatory processes we always uh uh some of the ACO stuff in the commercial rate review processes proprietary so some of that is in the executive session but we do usually explore them what's the hang up in terms of moving more quickly there so I think having a more public milestone chart or plan uh makes sense I do think it's important to include DFR because they have the regulatory authority of remarket conduct so um I would hope that we could include them as well in that effort and then I think that Jess asked the other questions that I had so why don't we move on to someone else thank you Robin Tom here we are Robin at the other side of Berlin um we just live across the valley from each other I'm very grateful for the work that you two have done and your teams in terms of putting this together because you know for me I'll be you know very frank about it sometimes I get lost in in all of the interconnectivity of all this and and just you know would like someone to come in and say here's where you got to go and once I have a target of where I got to go I can usually get there but um with it spread across this landscape it's a little bit difficult and so one area I want to point at is our recommendations eight and nine and you know in the the language is like identify clear milestones for including fixed prospective payments and move incrementally toward value-based incentives and I agree with that I mean I I I get the concept that fixed prospective payments are a key to the front door in all of this but then I look at some of the data and here we are you know in the third year of the all-payer model heading into the fourth and I look at the expenditures to providers through the ACO and their proposed budget for 2021 is 1.4 billion dollars and 33 percent of that is fixed prospective payment and nine at four hundred and seventy four million and nine hundred and thirty two million is still fee for service and I you know I don't know I mean I've talked to the staff about where should we be in these kinds of relationships and they're saying somewhere between 30 and 50 percent is when you begin to get to the point that you can leverage the improvements that we're all hoping for in the system so and in terms of our hospital budgets for 2021 you know of the total 2.8 billion in net patient revenues only 13.9 percent of it was tied to fixed prospective payments at 389 million so for me it would be helpful if we could get to a consensus sooner rather than later and I know of next next to the item number eight nine it has a short and medium term and number nine has a longer term the sooner I think that we can get to targets that we all agree on in terms of fixed prospective payments and as they flow through this system the easier it will be to explain what we're doing and and and how we're doing it and why we're doing what we do and why us battle regulators are insisting on higher and higher levels of fixed prospective payments so um I guess that's just my hope is that that eight nine can be put up on a higher priority that we can find a consensus among the board and the ACO and a chess to say here's where we're going this is the number we've got to hit and you regulators you play a key role in that in terms of rate review and hospital budgets and the aco budget and um so just to get some reaction on that it is a what what was the timeline when you say short medium term and longer term for eight nine uh what do you have in mind sure thank you very much short term was a week medium term was two weeks and longer term was a month I'm kidding no you're not no you're not I know you too well you're not kidding um we we have an index up there a short term is 20 and 21 medium term is 22 and longer term is 22 and beyond um I I do think you raise some valid points uh that we really need to sort of pinpoint that a little bit more um definitively I think is is the word I would use so um let's take let me take back that uh suggestion and look at this a little bit more well it would just be helpful I mean we used the three and a half percent number quite a bit um in our hospital budget guidelines and things I'm sure it's not a perfect number you know when we were up on the fifth floor the numbers we were using were perfect numbers but they were guiding and guiding stars and uh uh it's just it's just helpful to know know where you're trying to get to um because if you don't have it defined and you don't get there who knows the difference yeah so another area is uh in the plan at least in the narrative in the beginning it talks about health care reform activities at AHS not clearly organized for success uh um and in terms of the agreement's performance and there are a couple of areas that that uh I still don't understand why we haven't gotten there yet and one of them I'm and I'm very glad to see in the ACO budget this alignment of self-management plans um uh at the blueprint um but but I don't think that there's good alignment between the benchmark plan and um uh for example the blueprint plan on prediabetes in the blueprint plan there is no benefit associated with prediabetes yet this is one of the more severe chronic diseases that we're trying to address in this whole all-pair model um effort um and uh so you can go to a bronze plan and get a couple of sessions with a nutritionist but that's not in any kind of organized way tied to the blueprint's CDC approved plan for prediabetes and um which is which is the gold star plan from what I everything I understand so again I'm just urging that um that and I think it's more in Diva's ballpark to let's go revisit the benchmark plan let's not open it up to non-preventive stuff you know because I understand from Robin that who was around the first time that it can be a real food fight and and waste a lot of people's time so you know as a board member I'd be more than happy to put some kind of criteria on a review that just limits it to better alignment on the prevention front between the all-pair model you know and and the benchmark plan you know that we're asking the insurers to offer um so that's just a suggestion um but it just you know that that plan goes back to 2012 I think and you know a lot of the world has moved on since and um it's it's just that that non-alignment on pre-diabetes just is like a sore thumb to me and the other thing is the cost shift so so as you went into the the budget process with the legislature for 2021 there was in the presentation that that but for federally mandated increases there will be no increases in reimbursement rates for for Medicaid in 2021 and I just I and I understand the cost shift I'm I don't have clean hands on this either totally um going back but um you know it just worries me that that the cost shift is siphoning out of the all-pair model one-care efforts of you know savings and efficiencies that are being found um and they they don't stay within that network they get siphoned out to the cost shift and I'm just wondering if uh you know if at AHS uh you know looking at caseloads going down over recent years um if some kind of um standard guidepost can be set for on a per member per month basis or some other metric where people can have some assurance where Medicaid will fit in terms of their money coming into into um you know the financial networks that we're dealing with it just to me seems like a you know an unknown and we keep whistling by the great graveyard of of of medic of the cost shift and it's such a big piece of the pie that we can't ignore but we kind of do ignore it so that's just uh another comment the the third question was I was just wanting in terms of care navigating navigation and and the um what you you hear on that in terms of some people not liking it and some people loving it and I'm wondering if you have any breakdown of that commentary associated with the different quadrants of health I mean do people love it who are dealing with patients that are are are high users or very high users and it doesn't really do much for people that are you know kind of reasonably healthy or is it an across the board critique of of you know that that tool I think what we heard most and that's why the recommendation is crafted the way it is is that we need to sort of dig down terms if this is a user issue is this is a software issue or if this is a um a problem uh that the data isn't getting the right data isn't getting to the to the right people at the right time I think what we heard that it was all over the map uh board member Pelham it was all over the map in terms of this thing is terrible to this thing doesn't give me the information I need to brought a world you know hey this this gives me the information I need so we crafted the recommendation to say hey let's look at this to see what is going on here um and let's see if we have to redesign what we've been doing with and we're willing to help with this with one care to look at this uh together um so we we didn't we got to the to the level of there's dissatisfaction let's let's take the next step find out why there's dissatisfaction in this and that's what the recommendation goes to you know well I'll be yield back the rest of my time to Jess to see if she can ask you some other questions that uh those are my issues thanks um Maureen uh thank you uh first uh thank you for this presentation and and um you know really all of us collaborating together to kind of work move forward on this um a lot of my questions have already been asked but you know I just want to also talk about you know recommendation seven and um really how we get more participants on the commercial side when we look at um many of the players Vermont is a is a small piece of their pie if you look at a sigma or someone like that and you know how how are we going to get them to participate and without that you know and without having a larger amount in fixed perspective payments it creates a lot of strain on the system you know one of which we heard from the hospitals in particular where it was almost the reverse effect so what was happening is they're getting you know first of all the the care provided for everybody you know is going to be the same whether they're on the acl or not and the intent obviously is to provide the best care for everyone but we know one of the potential outcomes with the acl and what we're trying to do and getting to people earlier for their care is it pushes them out to lower cost of care centers and when the hospital receives fixed perspective payments for those patients if that savings is achieved for those patients that that's a benefit however for all the other patients what they're telling us is those patients are also maybe moving out to these other cost of care lower cost of care centers and and you know working on obviously the best quality of care but that's creating this huge gap then in their budget because you know they they have obviously high fixed cost so without getting into higher fixed perspective payments and getting more of the population in there you know we heard that was creating a great strain right so it wasn't just what they received from the acl and the true up on the acl it was really almost the true up on the rest of the population and moving that out so so you know don't know what the answer is right to get these players in from the commercial side but you know that's going to really be critical to get the scale that we need so don't know if you can add anything else to that and no we we heard the same thing and we probably heard it from the same same hospitals as well in terms of you know you got to get scale and one of the things that i'm hoping to be is persuasive to some of the payers on the advantages of coming into the the all-payer sort of value-based system i'm not going to be polyannish about it it's not going to be an easy sell but at the same time i i think we got to reach out to the payers and say look you know this is this is where we want to go how can you be how can you be partners with us as we move forward and figure out a way and and you know as as it has been said earlier i i think you know we're gonna we're gonna have to have partners in state government saying the same thing as we move forward so um i don't have a magic bullet on that but what the what the recommendation is driving at is i need when i can and there's a vaccine coming when i can get out um and get out and meet with these well i can still meet with them um but meet with these uh with these executives of these companies and say what can we do together and let's let's try to move that as quickly as we can um more on the short-term medium term side and and i know it's listed as longer term but i always drop things down a notch every time i read things so let's let's let's try that you raise a really good question that we just we've got to work through and then when you talk about um several of your strategies are on strengthening the acl leadership strategy and um you know we're obviously a small state in vermont we only have one acl um is that a pro or a con in in you know moving forward and um even nothing against one care just a question right is that is that going to benefit us so having just one acl or you know in a system would it have been better to have multiple acl for participation you know i didn't i didn't really here's how i approach it i've got what i've got and so let's let's make it work with what what we've got um i haven't i haven't even thought about that because right now i i don't have it uh so you know it it's a great question but it really didn't play at all in what what we were doing as we were moving forward here no i i agree with that too it's more just what who knows right but whatever you want that's all i had everything else that was really already asked so thank you great thank you moraine before i open it up to public comment i understand robin you have another question yes um one other thought that occurred to me that i meant to um ask you about is uh in the blueprint delivery system reform model there are really three components which are the payment itself um the data and analytics and then the practice facilitation and uh the way that model works at the primary care level as you know is practice facilitators are actually contractors of the state but the individual practice can choose which kind of facilitation they're interested in lean or six sigma or microsystems whatever and then the hard work of actually changing the operations is of course at the practice level we don't really have that for other provider types so at the aco level we have the payment change and we have the data and analytics which is obviously a key piece to make the delivery system actionable but we haven't really as a state identified whose responsibility it is to uh own that delivery system operational change which in my view necessarily has to at some at some level be owned at the provider itself because the provider needs to do the change to their own business operations but i was curious your reactions to that and what thoughts you've had in terms of our model and whether that's another area that we may need to kind of beef up or be more explicit about as a state i think we i'll let ena answer the the bulk of the question but i but what what sort of um caught my attention is not necessarily to be to beef up but the integration of the two um two systems that are out there um we got the aco we got the blueprint and the sometimes the two don't meet in the night uh and how do we bring the two together as we as we look at it and i think if if you read sort of the the the report it talks about that and how we can bring sort of i you know we everybody's working hard and everybody is rolling real hard the problem that we're having is the coxswain is we got three different coxswains and and they're they're they're shouting win the roll row at a different time and i just want one coxswain i just want everybody moving in at the same time at this uh at a fast speed i hope uh and and we're not seeing that with the two examples you just brought up we're just seeing a no integration at all ena did did did i get myself in trouble or did what did i do here you're on mute you're on mute i'll just smile my way out of that question and just um in in the recommendation um it's it's in the section that's about strengthening the strategy and um where where we say fostering a culture of continuous improvement innovation and learning through focus on data and systems for improvement robin you're talking about a system for improvement in the primary care um uh space that was established through the through the blueprint for health um program those quality facilitators are are part of a system for improvement on the information that's been provided through that program and i think you're right that those systems for improvement are not applicable across the entirety of the integrated system that is a part of this a part of this model and where services are subject to the total cost of care target and i don't know that we have a prescription for for that in the report but it is an area certainly in relative to um the entrepreneurship relative to thinking together about how we how that is accomplished because that that work does have to be accomplished for more than simply the primary care system so i i would agree with you um and that's an area to work on clear steps aren't in this report but i think that's something we can work towards thank you okay i understand that board member holmes has an additional question sorry sorry sorry one quick question that i forgot to ask but it was about recommendation 16 and that was around incorporating the social determinants of health screenings into the standards of care i just want to say i applaud this initiative but i realized that more screening is going to undoubtedly uncover greater need particularly around mental health and substance abuse so um and providing those community support services so i just wondered if you had planned for increased resources available to meet that greater need and or is our community support system going to be ready to handle more need that's going to be uncovered and again i applaud the screening additional screening but just want to make sure there's going to be enough support to to meet that need whether that's been considered yeah i think you know we've been looking at um these areas um pre-covid and during covid and hopefully post-covid um and we'll continue to look at these areas um i don't think it's been tied specifically to this recommendation but in general the agency has been looking how how do we determine um you know it's not only mental health it's it's it's food security it's a lot of things that are out there education a lot of things that are out there so when we talk social determinants of health um you know and i've said this before i'm a big believer in social determinants of health and what it can do to sort of bring our our cost structure under control uh as we as we move forward so we're going to have to we're going to have to you know integrate some of this with the larger agency sort of mission as we move forward and and throughout the um in various parts of the report we talk about bringing the agency um along with what we're trying to do here as well and i think you pointed out a one of those areas we're going to have to focus on okay thank you that's quick thank you thank you i'm going to open it up to public comment does any member of the public have any public comment and i just saw a hand go up it's mort wasp it's mort wasp and go ahead mort hi uh thanks for allowing the public in on this fascinating discussion i had a couple of comments that have to do with technology the tendency to want to demonize or turn to some form of technology uh demonization meaning oh this is terrible that's why we can't do it the example here is care navigator the very fact that braddle borough finds this tremendously useful and everybody else or lots of other folks find it difficult suggests that the problem isn't the software but the system in which the software is implemented and i know from having been a clinician that the thing that maddens clinicians of all sorts social workers care coordinators physicians nurses pa is is having to do something twice because there's not even enough time to do it once so i think that um it's easy to demonize care navigator and there's plenty of problems with it but the real issue is find out why braddle borough works and what can be done to help the rest of the health service areas in the state be more successful whether or not you stick with care navigator or get a new tool the second thing was really a question just because i think that the integration of electronic health record data and claims data is some sort of uh holy grail in making systems better but and the hie has has taken incredible steps to become more sophisticated and getting data to one care and having single individuals identified ninety five percent of the time but claims are a completely different beast because they're not mature for six months so the notion of some sort of real time claims uh EHR integration is really challenging and it might be uh not worth what you can get the real gem of integrating claims is to find out what actually got paid for pharmacy is one perfect example where electronic health records just tell you what was ordered but not whether anybody ever picked it up at the pharmacy let alone took it so i i think it's a great idea but probably more of a long-term solution i'm excited to hear that there's a pilot going on with medicaid which is i think the most workable group right now thanks and more just to jump in on that it's not that at least from the the doctors that i've spoken to that they thought care navigator was useless what they the problem that they were referring is that they felt they had to try to have three screens open and it wasn't practical and that's uh the feedback that that i've gotten at least no i think that's correct you mean you have to jump out of your electronic health record into a second system and that's and and that actually if you you can interface the two systems but that's a lot of work and the interface has changed all the time so but i i agree uh chair mullen that's exactly uh one of the big problems okay thank you other public comment kevin mic fisher here go ahead mic good afternoon thank you um i guess i want to start by appreciating the call for uh transparency uh and um and transparency of data um i think that's important and i think it's both important for the board and for the public i appreciate that um and then i also i i think i'll make this more as a statement than a question because i think it's a big question it's a big it's a big statement um and it's sort of in line with a question that member holmes asked earlier um given the financial stress that uh hospitals describe um which by the way is very closely related to the financial stress that vermonters uh small businesses and uh other purchasers are experiencing i'm afraid that it will be that that the nexus between uh reducing the risk such that um providers will be able to participate while at the same time driving the kind of system change we're all hoping for here pushes in opposite directions and and i i just am i'm worried about that um and then i'll also say um as long as we hear from vermonters who can't afford to pick up their insulin or similar stories whether they be from the commercial marketplace or be on medicare um consumer affordability is pushing in exactly the wrong direction here and and as long as those stories continue to come to me um you know or we continue to struggle with trying to find strategies to deal with those dynamics um uh our work is much harder in uh in in bringing about the change that that we're all hoping to achieve here so that's my comment if you if you have a response i'm welcome and if you don't that's also okay so not hearing any um i'll ask for other public comment well thank you very much mr secretary and madam director um we applaud the work that you've done to date on this and thank you for your leadership and um the green mountain care board is committed to doing all that we can on our end to um make sure that this model is given a fair chance so um thank you very much well thank you for your time and uh happy thanks giving to all of you and just keep in your thoughts we have a lot of state employees working uh tomorrow and uh and friday so uh keep them in your thoughts as well so thank you very much it'll be a strange one my wife thought that any opt to uh cook the standard feast and now uh there's two people it's uh it's going to be strange uh as as but if we all behave the state of vermont will be much better off and if we don't the uh the trajectory is scary so um so we'll uh we'll see you later thank you very much bye now thank you thank you happy thanks giving to you too well thank you thank you walley that's the highlight of the day yeah it is and it's tough to even transition from that to the next discussion but susanna are you going to tee up the next discussion for us sure it's it's pretty straightforward and i don't know um ena if you'll be able to oh she just went off i don't know if she'll be able to stick around it's fine if she can't um we are just going to give a um brief overview our staff uh elena baraby and sarah kinsler are going to give a brief overview of a response to a uh warning letter we received um a couple of months ago and then um they have a request to and they'll get to this through the slides to delegate um the chair uh chair mullen and staff to continue to work on this letter but they will get into all of the details but we'll review the high level parts of the letter have a discussion have public comment and then uh go from there and i and if i would assume we'd have a vote too um when they set that up for you if you're ready season so we'll turn it over to elena great thank you um so i will share the slides you know and you can see we can see them great so i'll just give you kind of follow up a little bit um on what susan kind of laid out so this is um about the scale target warning and the response that we've been working through so in this presentation we'll go through background review scale performance to date um talk about the work that the staff at the board have been doing in this regard even prior to the um issuance of the warning um and then you know the work that we've done to formulate to work with our cosignatories to formulate a response and then we'll outline next steps and hopefully have a vote um and i'll turn it over to sarah to get us started kinsley sure thanks elena um can folks hear me we can excellent um so a little bit of background um we've known from the start of the all-pair model agreement that the scale targets included in the agreement would be a real challenge to achieve to achieve and and we know that because to be attributed takes a couple of steps so in order in order for an individual to be attributed to an aco and count towards scale they have to be covered by a participating payer and then they have to see a participating primary care provider in those cases um so there are a couple factors that go into scale that we look here um provider participation or the aco's network um as folks know this is a voluntary model so the state does not require anyone to participate secondly payer participation again voluntary model for payers and there are some types of payers over which the state does not have any control or kind of regulatory influence and that includes medicare advantage plans self-insured employers and federal employee and military plans and then finally care patterns and attribution methodology as i mentioned earlier in order to be attributed to an aco an individual has to see an aco participating provider but what we found when we first started measuring scale was that the surprising number of vermonters get the majority of their care um out of state either because they were in a border community so for example people who live in eastern vermont and seek care at dh or snowbirds who get their care down south for part of the year or some other reason a 2018 analysis um that our data team performed which was actually included in the performance year one scale report showed that even if every vermont primary care provider participated we would be under 80 percent for for medicare scales so under 80 percent of vermont medicare beneficiaries would be aco attributed either because they seek a lot of care out of state because they didn't have any historical spending to qualify them for attribution or or maybe one or two other reasons thanks alina so considering all of this we can see that the scale targets in the agreement are extremely aggressive especially for medicare where we're tasked with bringing 90 percent of medicare beneficiaries into the model by the end of the agreement as you can see we have a problem there um this chart lays out our current performance um and as a reminder the board reports on the state's performance to cmmi annually every june six months after the end of these performance year um so that here we list um we list performance for py's three and four and those estimates are really preliminary so we won't report those until 2021 and 2022 respectively but we can estimate future performance based on the eco's budget submission and based on data that we receive for medicare as you see we're still quite away from the target especially for medicare the next slide um is a chart which shows um which shows a little bit more light um and shows that we're really excelling on the medicaid side in terms of participation but that medicare is not meeting the targets and commercial is lagging especially self-funded plans um because we've anticipated that meeting scale targets um would be a challenge from the start the state's been really working on strategies to improve scale performance since the start of the agreement um so to give you an overview of a couple of these efforts in 2018 as we were first working to develop the scale measure specification the signatories discussed potential changes um to the scale denominator with cmmi or i should say that signatory staff um discussed potential changes to the scale denominator with with cmi and that that resulted in the exclusion of patients who are enrolled in medicare or medicare for partial benefits so for example only medicare part a or only part b um and and folks with medicare limited benefit packages um some hard to reach populations were already excluded for the agreement that includes the federal employee plan trycare and the uninsured and then there were a couple of populations where federal partners were kind of not willing to bend at that time um and those include the self-insured even folks even self-insured plans who weren't who aren't submitting to vcures so we don't we don't have um data on on members of those plans um we think that that's about 85 000 members based on prego bay vcures data um medicare advantage plans which at the time of that analysis in 2018 was about 11 000 people but we know that this is growing um and then medicare members were ineligible for attribution for example because they hadn't been continuously enrolled for for 12 months um then in 2019 the board in ahs fielded a survey of hospitals and f2hc's to understand opportunities and barriers to increase in participation on the provider side findings for that survey are available at the link that i embedded in this slide um findings also identify some strategies to address the issues that were found to be barriers and the state federal partners in the aco have made some significant progress in addressing some of these the aco was also identified as the lead for many of these strategies and it's asked to provide details on their sale strategy annually through the board's aco oversight work so now the the letter that um executive director barrett mentioned um the board or executive director season barrett received a warning letter in september notifying vermont of a triggering event for um for the all-care model agreement um that the that vermont had not met scale targets for performance years one and two as we talked about a few minutes ago um it's the board who supplies the data that kind of informed that's termination so this was not unexpected nor was it a surprise to us um our response uh is due within 90 days of receipt so we haven't told december 13th to respond on october 12th uh executive director barrett sent an acknowledgement letter um to sam and i indicating that the signatories would work together to develop a response and since that time board staff have been working with the other um signatory staff to do so and i'm now i'm going to hand it to elena to talk about the strategies that we've identified in that through that process so there are really two components of the scale targets the denominator which sarah talked about at length about what were measured against across the state in terms of population and who's included in the model the numerator captured who is included in the model um so you know and that's broken out into two primary groups the medicare scale and all-payer scale um and for all-payer scale because we've already talked about the medicare strategies we'll talk about commercial strategies and strategies that can really um kind of link across all-payer types um and a lot of these are going to look familiar because um they were developed and then included i think in in the um hs's report and so you know i think a lot of those will look familiar to you so we won't spend too much time going through these all over again but you know we talked about the reduction in the risk corridor this allowed rutlin to join the model in 2021 so that was um a good good result uh proposed benchmark um for 2021 to ensure that that's stable to allow providers um some confidence in continuing their participation um requests that cms offer written guidance for best practices uh for cost reporting for cause receiving medicare prospective payments um and then thinking about you know how we evolve the medicare payment and attribution models um as we go forward the commercial strategies you know i think we're excited to hear that the state employees have um have are now joining the um the model um you know i think you know spoke at length about you know the education that um is expected to kind of unfold around self-funded participation where there is the largest opportunity um you know we can think about teachers hospitals and the broader business community um and then for the all payer strategy you know i you know sarah mentioned that uh this is something that we already kind of look at in our aco oversight process so we will certainly continue to ask the aco to report on their scale strategy provide any updates to the activities that were identified in the 2019 scale survey um that was conducted by the state and then submit um a work plan to so we can understand how they they expect to achieve some of those goals um activities outlined in the survey um i think issuing the health care provider stabilization grants was um was very helpful and um conditioning those grants on value-based payments so we did see some participation um kind of um linked to that work and then pending the aco budget review you know this certainly needs to go through the board process and staff need to complete and come to you with our aco um budget recommendations but you know we can start thinking about how could the aco intensify its all payer approach to provider participation or how could it refine its risk model with the goal of statewide participation across you know variety of um payer types um so next steps for the letter we would request that the board shared um or that the board delegate to the chair to continue working with staff um and the apm signatories to finalize this response um and if that seems appropriate that we've adopted some language here with the help of our legal team and then um you know the reason why this would be so helpful is you know while december 13th felt so far away it's it's now just around the corner um so we still need to kind of finalize the letter route for signature and submit the response to cms by december 13th so that is the goal and turn it back over to you kevin if there are questions thank you alayna questions from the board i guess i had more of a comment than a question you know i think it's good to go back to um cmmi to talk about changing the denominator i'm not particularly optimistic about that because quite frankly i've we've done it twice um but i i think it's good to do it again um but i also think that and i guess this is more of a comment for you kevin because i think it the process wise it there's really no way for us as a group to kind of micromanage sending a response so i'm all for delegating it to a board member to work with staff on but my comment would be i would be concerned about um potentially reopening all of the agreement targets should that be a path to go down and and that's something which i think we're gonna have to face in 2.0 which is right around the corner so that would just be a thought is that um i think it'd be good if it if that those jail targets were more aligned to our actual authority but uh i don't think it's necessarily worth it to do a wholesale renegotiation when we're about to go into a renegotiation so just a comment understood other board members what a quiet group would anybody like to make a motion i will make a motion um that the board delegate authority to the chair to work with staff and formula and the other signatories to the model in formulating a response to the warning letter i'll second it it's been moved and seconded is there further discussion well actually i think we should open it up to uh public comment as well um before i open it up to public comment though is there any board discussion hearing none i'll open it up for public comment hearing none we'll go back to the board and um is there any further discussion if not all those in favor of the motion signify by saying aye those opposed signify by saying nay let the record show that the motion uh carried unanimously is there any old business to come before the board is there any new business to come before the board hearing none before i take a motion to adjourn again i just want to echo the earlier comments and wish everybody a very happy Thanksgiving it'll be a Thanksgiving that we'll never forget as we sit in our small groups but we're getting through this there is light at the end of the tunnel and at someday we may actually have a board meeting in person so um with that is there a motion to adjourn so second it's been moved and seconded to adjourn all those in favor signify by saying aye don't eat too much turkey have a good one folks bye happy Thanksgiving happy Thanksgiving