Good morning everyone so I have a couple of announcements first on the schedule for December we have today's meeting and then where we're going to hear from our ACO benchmark presentation we'll hear from the recommended from our ACO APM team on recommendations on the 2021 year budget next Tuesday the 17th announced that I want to announce that the World Health Services Task Force will be meeting at 9 a.m. that's in this room Robin I mean this building fourth floor comfort upstairs yep and then on Wednesday December 18th we'll have our regularly scheduled for meeting starting at 1 p.m. in this room we will have the green out here up the one care ACO budget with a potential vote and then our analytics team is going to present our research and reporting priorities for 2020 to 2022 I also want to make a clarification on today's agenda as I said we're going to first hear from Sarah Lindbergh on our ACO Medicare Bunch benchmark proposal we have listed a potential vote but we will not be voting today we are awaiting additional clarification on some data from our federal partners and that's all I have to report thank you Susan next item on the agenda are the minutes of Wednesday November 20th is there a motion so moved second been moved and seconded to approve the minutes of Wednesday November 20th without any additions deletions or corrections is there any discussion seeing none all those in favor signify by saying aye aye any opposed so now we're going to move to the ACO benchmark proposal and welcome Sarah Lindbergh to come forward operate with me good morning Sarah Lindbergh health services researcher with the Green Mountain Care Board as Susan already said the proposed vote today will have to be delayed due to some data legs and and refreshes that are going to be required to finalize the benchmark however I thought it would still be prudent to just go over some assumptions and sensitivity analyses as they relate to the Medicare benchmark for our all-pair model financial targets so among other things whenever we propose a benchmark the agreement says that we have to meet certain conditions in order for that benchmark to be approved by CMS and there's the most pressing on my mind are these two financial targets so whatever benchmark we set must enable us to meet two different financial targets and these are all-pair models statewide agreement deals not just ACO deals so it's a broader lens than just the ACO budget so we have to say that whatever benchmark we're at we that we propose will allow us to meet our all-pair total cost of care growth target which is 3.5% or less compounded over five years so that's from 2017 to 2022 but that we would need to show that we're kind of on track to meet that goal in order to sell the proposal successfully and sell us a strong word to have a proposal successfully approved by our federal partners we also have to make sure that we're keeping our total cost of care growth point two percentage points at a minimum below the national projection so that's where that call letter and the budget kind of trend rate that guardrails come from that part I think we're probably more familiar with than how this folds into the all-pair statewide idea so just kind of helps me to put into context how people and spending aren't the same thing when you're looking at this stuff so if you look at our statewide total cost of care estimated for through with three months of run out 2018 Medicare represents 44% of the spend even though it's 27% of the people so they have kind of a high higher influence per person than other payers it's a little bit more congruent for commercial and again this is just data available to us in our all-pair claims database so that's an important caveat but of that subset of information it's 44% of the people and 40% of the spend in the commercial market and then Medicaid while they have 29% of the people as their primary payer it represents 16% of the spend another caveat is that this is total cost of care spending so right out of the gate we're excluding about half the Medicaid spend for the total cost of care because that is excluded from our total cost of care as defined by the all-pair model agreement so there's certain things like we said hey we're doing pretty cool stuff with home-based community services and mental health let's not mess with that anymore let's just keep it kind of Medicare A&B type services so that's why the Medicaid spend is kind of cut in half for the agreement purposes so when we look at what was budgeted by the ACO for 2020 you can see that again the the slopes are similar but a little bit more dramatic in some cases so the commercial as budget is pretty much one to one 41% of the budgeted number of people they expect to attribute and 40% of the expected spend but here's where it gets a little more disproportionate Medicaid represents 37% of the budgeted attributed lives and 21% of their budgeted expected spend and then Medicare again we see that kind of dramatic slope where even though it's only 22% of the attributed lives they budgeted it's 40% of their spend all this is to say and I've said this all along this thing's probably gonna go the way Medicare goes it's it's that's the kind of the the most influential point as more and more people are aging on to Medicare that's what I think this model is really gonna hinge on and that's why I think that setting the Medicare benchmark is a really important thing to focus on when we're considering the obligations for the all-pair spend and stop me along the line and weigh if you have any questions when you're talking about the Medicaid percentage going down right being a lower percent than population and part of it you said was because some of the services are provided elsewhere but isn't it really the benchmark number because it's so low PMPM so it's like a 200-something number versus a 800 for Medicare exactly you're talking about this percentage so it's less money per person right yeah absolutely that's a huge part of it right but this wouldn't be quite as dramatic if this were times two that's what I'm saying okay okay for the full picture of Medicaid spending thanks okay and so these are you know it's pretty hard to project the future but just kind of looking at very high level so we feel pretty good about where we think 2018 is landing again this is for the all-pairs statewide whether or not you're attributed to the ACO these are the all the folks that we're accountable for for our spending when we talk to the federal government and you'll see right away we've got a problem this is not right this number is not going to be point five percent after we get our data right so that's that's not a good number to be anchoring on so right now we're predicting the commercial growth to be point five percent that largely has to do with some some problems are getting fixed with the data feed from our largest a large commercial insurer and so that's going to probably go up closer to what we've historically seen in the five to six percent range so so that that's built into these assumptions and I'm projecting forward but I just want to be transparent that we know that we have a bad estimate there so as it stands the Medicaid growth is pretty dramatic from 17 to 18 so we're observing this is without any adjustments for price increases this is a seven percent growth rate that we're seeing from 17 to 18 statewide where Medicaid is the primary payer so this is you know something that our partners over at Medicaid are aware of and are starting to investigate some things that we see in our data are there are changes in the amount of utilization by the Medicaid population and also the type of utilization so the big one is acute inpatient hospitalizations are up and also that might also be where they're getting hospitalized this has a higher unit cost so there's a lot of stuff that's going into this seven percent but that's a statewide Medicaid thing I think one thing that is really important to be aware of is that for the ACO the base year was 17 so their 19 targets probably pretty lousy for them and I think that that that'll be adjusted because from early indications it doesn't look like this growth rate is likely to continue into 2018 2019 but you know it's still early hard to say for sure where that might land and then for Medicare so these are allowed amounts that's another important thing to keep in mind this will include the you know 20 percent cost share that is borne by the member so the numbers you see with the ACO budget are paid amount so that would just be the amount that Medicare is on the hook for so through putting 18 months of run out we see a growth rate of 1.8 percent against statewide that includes people who just have only part a of Medicare only part B it's a much different population than where it is in the mix when we're talking about the ACO population that's likely to go up a little bit with three months of additional run out so that puts our all payer growth rate at 2.6 percent back of the envelope we think that probably land right around 3.5 with that additional three months of run out in the correction for the commercial market spend so if we were to kind of project out some low growth and high growth scenarios I see you know the probable range between 3.1 percent and 4.9 percent that would be compounding annualized growth from 17 to 20 so that's what we're on the book for so that's a what's suspended 2020 divide that by 17 take that to the number the third power and that's the annualized growth rate that I'm projecting if I look at the most likely scenario I think we're probably 4.3 that number is important because if we're to exceed that that's when we get in big trouble for sure with our federal partners again all payer system-wide growth that's assuming that our statewide Medicare growth is it's been pretty stable at 2.2 percent so that would be making the assumption that that assumption were to continue if we assume that the state grows at the max what the national is projecting everybody does that's we get a 3.3 percent trend rate and due to this slide when this goes up it affects this a lot more than when this goes up so when Medicaid goes up the bottom line isn't as sensitive just because it's less dollars even if it's more people it's fewer dollars and that's why the all payer is less sensitive to that I mean there are lots of numbers and I think people are not you know clear on everything can you talk about where 2019 like you know we're going we have 18 we have 20 yeah 19 in the mix just to explain why they're in there and so I so the reason I don't have the 19 data publishes I don't have 19 data available yet so I'm just extrapolating from other data sources so I wanted to keep the data source consistent but from what I've seen for early 19 I think that Medicaid looks within that range maybe would go as high as 300 is one possible projection I've seen commercial is the hardest one to project but I'd say you know that 6% has been kind of the average growth over the past five years so I would expect long term the 6% growth rates pretty pretty stable and then Medicare the 2019 numbers we're just starting to look at the information here but statewide I just don't have enough information to be sure where that's landing for sure but I haven't seen any evidence that statewide we're likely to exceed that kind of 2.2% trend so and I guess what I'm going is you know you talked at the beginning about the 3.5% yeah you know compounded five-year we're not to exceed 3.5 is the target and then you mentioned the 4.3 can you just talk a little bit about what the 4.3 triggers sure yeah so the difference between 3.5 and 4.3 so as Robin has educated me from her experience in the negotiation is it really depends on the economic picture that you use to project kind of inflation driven growth so lousy economic projection was 3.5 percent economies growing slower healthier economic perspective was a 4.3% so that's why they said well let's say that you're not going to get in trouble unless you exceed 4.3% so that's the trigger for corrective action at a federal level that said there's a lot of latitude in the language of the agreement so that they could I don't think that that number of chiseled ones in stone so if we are showing they're not on track they have the latitude to start a corrective action. Okay can I just jump in on that point so to Sarah's point the targets were set from prior economic growth those don't get recalculated based on new economic growth just to clarify that point and I think I personally would not characterize the 4.3 is big trouble sorry Sarah it is a technical part of the agreement that would allow the feds to choose to come to us and say okay we want to dig into why your growth rate is exceeding economic the previous economic forecasts let's investigate what's going on that could result in some modifications to the agreement it could result in nothing happening so I think it basically triggers a negotiation and a review. No that's much fairer characterization sorry to be an alarmist. Any other questions about this okay oh yes and just a quick one so that 4.3% is a is that that's the trend rate going back to point 17 yeah that would be the average yeah based on what I think given my very limited information what I consider the best estimate for the projected growth which is worth about is what this okay no I don't know so yeah so again just just remind people that that national growth is the other portion of the financial target that we have to make sure that we're meeting when we propose a benchmark and that's where these annual kind of ceilings for the trend rate used in the growth 3 come from so that would be the you know 3.96 for the non ESRD and the 2.94 for the ESRD population so so that one's kind of the easier one to demonstrate clearly that we're fulfilling if we're using these national projections and use trend rates that are in line with those things much harder all pair part of our obligation so so that's just some background about why we're recommending a trend rate of 3.5% for the non ESRD trend rate so an important thing happened so there was an error in the calculation of the number of prospectively aligned beneficiaries for Medicare the an inaccurate provider list was provided was produced to the people who run that that process and so that means that one good thing is that this number feels a lot more reasonable on to everyone because the 19 and 20 networks are so similar we would expect the number to be similar instead it had gone up by 20,000 people and after a lot of investigation we it came to light that the that this was based on the wrong provider list so as a placeholder for this recommendation today I'm just using the prospective attribution from 2019 that's not exactly what it'll be it'll be a little bit different hard to say if it's up or down likely it'll go down by a few hundred people if my estimates are any guide and then we also have a current updated estimate to our the to date of what we think the base experience is so the the upshot is that both these numbers are still being worked out exactly so this is the estimate for the 19 experience the estimated attribution for 2020 and then here's that 3.5 percent trend rate so as we saw on the previous slide we could go as high as 39 and fulfill the Medicare obligation under our agreement every time you increase the this trend rate by point a tenth of a percentage point so if this goes up to 3.6 percent the benchmark would grow by five hundred eighty two thousand dollars in some change and the PM PM would go up by 83 cents so the the amount the benchmark will change will be sensitive to both these numbers the PM PM will only be sensitive to this number based on our current estimate it would increase it by 83 cents so that trickles through not 100% but a great most of that increase goes right to the all-payer because even though the scale for for instance in 2018 even though the Medicare scale only represented just under 30% of the Medicare lives it was 48% of the spending in 2018 so the ACO people who get attributed are more expensive they are utilizers so when you are attribute so the ACO spend kind of market share is greater than its people market share so we often think of scale in terms of people but there's also kind of a spending scale and so that you know 80 cents or whatever is gonna probably about 60 cents of that that's gonna trickle through so I apologize I shouldn't have rounded there it's not a full dollar it's it's about 64 cents is how it would contribute to the all-payer growth and every two percentage points that that goes up makes this number go up by a 10% so say that another way if we were to use 3.7% instead of 3.5 I would guess this would be 4.4% so if we try if we were to just increase the ACO's benchmark by 0.2% point so 3.7 instead of 3.9 my estimate is that this would go up to 4.4% so on that flip back one no right there so on the 58 575 it's accurate to say wouldn't it be that we would take the current attributed lives add a couple of FQHC practices that are coming online subtract Springfield and subtract deaths and that would give us the number not the deaths because we start fresh every year they're okay yep we always take live people yeah so yeah so every year new people are turning on the Medicare that's true yeah and you have to adjust it for utilization crowd if so all those providers but then if those folks haven't utilize services that they're they're going to the ACO provider yeah the good news about the air is that there were some providers that were from what I understand added pretty late that they were not able to include for the attribution last time so this time we'll be able to include them so we're we're really hopeful that attribution will be pretty steady across the two years despite the loss of Springfield from the network would you estimate the margin of error could be on that number oh golly that is not announced I specifically did but when I just looked at the data available to me and I look at 19 and 20 I think I lost about 300 people okay yeah I don't think it's gonna be super material to I mean it's certainly material but I think getting this number right is critical if we know that we're dealing with the right population but it's very likely that it will not change the analysis the analysis oh the 3.5 is you know that I think you know even if you know if this if this is not the right number it needs to go up we'll have to live with that but I'm real worried that that we're putting ourselves in some behind the eight ball in terms of meeting our obligations but or you know having the opportunity to revisit the targets that's another they would really hasten that conversation okay can I just I just want to make sure I understand what you just said on that chart there because I think this is a really important chart and your best estimate column is really important to the extent that really what we're looking at is the all-payer total cost of care at 4.3 and what I think I just heard you say was if we hold constant the Medicaid growth that's a 3.3 percent which is your best estimate we hold constant the commercial growth at 6 percent which is your best estimate and Medicare if you were to allow for example the 3.9 which we are to some degree allowed to do and still hold our all-payer model agreement because it's 0.2 percent below the call letter but if we were to do that that would get our all-payer total cost of care to 4.5 percent is that your that's my which would be above the corrective action sort of trigger yeah and so and then so the other kind of piece of it is this is something we present to CMS for them to approve or deny and I don't I just have a hard time seeing how we could get an approval for something that would knowingly exceed our corrective action target thank you yeah and then nobody cares about the SRD but they're always here and so again because of the call letter the maximum allowable trend rate there is 2.9 percent so this is a very expensive population which also means it's highly volatile so as much as we can help protect against that risk in for this population you know I'm all for that it ends up not being a ton of dollars proportionately to the full benchmark but it is a very expensive subpopulation and one that requires a lot of intense care and management and coordination so you know that's that's a target that you want to get right if we can or at least go ahead and then we continue to strongly advocate that we allow the blueprint and sash dollars to continue to be distributed in advance to help with cash flow and funding these important programs I got some late breaking news yesterday where we think that that 8.2 might look more like 8.4 based on the current attribution so we're actively talking to our federal partners about making that change I'm optimistic that they'll I mean they they get the value of this program and and certainly want to support it so but that's another number that would necessarily be formal finalized here so so essentially none of these numbers are finalized but but this is our best estimate for the base experience our best estimate for the respectively aligned populations are recommended trend rate for you to vote on next Wednesday our best estimate for the base ESRT experience best estimate for the respective attribution our recommended trend rate going forward and then that blueprint money which may change a little bit so that would lead the the actual benchmark to be much closer to what was budgeted and again on a PM-PM basis we're very close but the main difference is that these numbers have come back to reality essentially so that mysterious 20,000 lives that no one could figure out where they're coming from shouldn't have been there so we're gonna get that right and that's part of the reason we asked to delay the vote so that we can have a little bit more confidence about this final number before you guys vote can you just clarify why the 8.2 went to 8.4 and how it relates to attribution sure on so just like we're talking with different three fives different attribution so the blueprint attribution program is a separate process and so these dollars don't necessarily go to one care folks this is funding a program that's bigger than the one care network so that is why they you know they did their best to guess what it might be but then on top of that there's some inflationary adjustments to the blueprint rate so those two things together kind of made it go up a little bit but you know kind of a but these numbers a little close to a drop in the bucket so I'm not sure I understood the answer to the question is there a simple equation that calculates that 8.4 yes there is I can share that certainly there's an equation I can share absolutely great thank you yeah the one thing I would just chime in about the stuff is one of the benefits of the model was a continuing the Medicare contribution to blueprint and sash but also having a trend rate prior to that to this model in the original agreement with Medicare it was a flat amount and it did not change yeah that is a really that's one of the nice things about having a state model is to have that kind of flexibility another real nice part about the state flexibility is that for a standard next-gen program three percent of this has to be at risk for quality which is a big number that's a lot of dollars that are at risk for quality but because it's a our state agreement we're able to keep that at point five percent again in 2020 we'll have to start increasing that but I think we'll have a flexibility to make it more gradual and you know true to the program the only thing I would say is that when you think about these PMMs so they are necessarily directly comparable to previous years and that's another thing that we're trying to do to help add some sustainability and predictability to the model is that in previous years these numbers would have changed that settlement but we're trying to have a number that stays the same prospectively as it is that settlement so you always know what your true target is and so that will already take out some adjustments and we actually included an additional adjustment for some high-cost inpatient expenses so there's some if you're particularly complex inpatient case for Medicare you get an outlier payment so we've taken that out so if you were to have an influx of those high cases high cost cases you know that that would add a little bit additional risk protection for those events other questions for Sarah okay we'll open it up to public comment do you get it yes only because I've had remedial classes let's just say that this is a really important function that we've got to get right we can't get the wrong number or we're we're placing the reform efforts in jeopardy and it's something that's keeping us up at night as we try to make sure that we get the correct information and that's been a struggle sure you explain that to me I can explain it to the public and either you know she can't what part can't you I mean I've just seen it for the first time so it's just a blizzard if I had it would take at least probably an hour and a half two hours with Sarah to disassemble that and turn it in neighbor so I think that Sarah would graciously agree to give you an hour and a half of time and we're going to really miss her too yes in the back I think they would they would argue that they're attempting to they do try to do things they try to tell that there's no regulatory authority but for example things like the Attorney General's office there through the charitable trust division tries to exert oversight over possible acquisitions and mergers and things like that I think that if you look at the traditional growth and health care spending pre Green Mountain care board and after Green Mountain care board you have seen a decline in the growth and total health care spending in the state of Vermont but keep in mind that the Green Mountain care board only has influence over half of the health care spending in the state other questions or comments yes I would just like to join this what an hour so my name is Bob Zealof Bigport so if that's ever set up just let me know the time and if it's okay I'd like to join that can you give your contact information to Sarah sure okay anyone else could be quite a party anybody else want to join okay thank you Sarah it is very difficult to understand and I know you've tried to make it easier for us non math peaks to get everything but it takes time okay so with that we're going to transition to the staff recommendations on the OCB budget and invite our team to come forward yes there are 100 slides that we are going to try to get through as efficiently as possible we wanted to kind of provide the public with as much detail as we can and in the board some background so today we'll talk to give some background on the ACO oversight process we'll review public comment that we received today we'll go through the certification eligibility verification the budget review we'll have a number of key topics to address there and then we'll summarize our recommendations that we will have presented throughout the presentation identify next steps and take questions or robust questions in public comment we do want to you know we've heard this conversation about we did not take the acronym out because we wanted to try to keep a simple presentation but there's a list this list you'll find printed for your convenience at the front and we'll kind of work to make this a standard product and perhaps build a philosophy at some point for a public perception so that's fine to have the list and it's fine to try to make it easier to read the slides to use the acronyms but when you speak please try to be acronym free thanks so this slide we've just presented recently so it might be familiar to you why we have the Altium model to begin with there's a problem that the state was aiming to solve to reduce the to control the cost growth in healthcare while maintaining quality of healthcare for the monitors the strategy was too prompt to to reshape the care delivery system through payment reform and ACO was seen as the vehicle to affect that change so this was the logic model that kind of coincides with this strategy so population-based payments that are tied to quality and outcomes increase investment in primary care and prevention we need to transforming the healthcare delivery to improve quality incorporate social determinants of health and invest in care coordination and in theory this should improve access to primary care result in fewer deaths due to suicide drug overdose and reduced prevalence and morbidity of chronic disease so we wanted to show you know simply how these relationships just you know under the Altium model work so CMS contracts with the state their number of signatories the authority kind of flows through the GreenMap care board to oversee the ACO then contracts with the payers and the providers this is for your reference a little bit more information on the roles and responsibilities of these different signatories and kind of what they bring to the table so again what we're you know this model what it needs to do is to limit cost growth this is you know referencing the benchmark that Sarah Lindbergh just went through and this 3.5 percent tied to economic growth there's a Medicare target we in that all-payer model target and we also want to ensure alignment across payers to support participation among providers as we think about increasing scale so the all-paying target for your out your five-year agreement is 70% of all remontories while the Medicare scale target is 90% bring those up in one detail year-over-year later on population health and quality measures there are 20 quality performance measures and three key population health goals improve access to primary care reduce deaths due to suicide and overdose and reduce prevalence of morbidity of chronic disease. To remind you again that there are a number of levers within your control to affect how the ACO does its work what is the ACO budget review process ACO certification process in the Medicare ACO program design and rate setting. So these two key processes certification and budget certification occurs one time so that happened the first year the ACO was in this model and then there on we certified their continued eligibility annually but continue to receive documentation throughout the year any changes in policies and procedures that might alter their their standing so we keep track of this as the budget review occurs once annually and results in the budget order which is kind of the deliverable after after the recommendations are solidified and voted on. We wanted to just quantify the work that we've done to date this is a very crude estimate of what the team has gone through and it does not include everything all the additional analyses that have come forth with it but we've reviewed 714 pages during the budget process 46 pages during certification this does not include review of all the policies and procedures held by one care which is hundreds of pages in a public comment we have 26 pages that was as of the third and there have been a couple more that have trickled in but we've read those in great detail and considered all the public comment as we conducted our analysis. In addition together with the HCA we've asked one here 88 questions this year that does not include kind of sub-questions more granular questions and some of those questions were actually please submit and then some data tables along with that. So as you think about the all-pair model and through this ACO oversight process we might kind of bring these things together you know how do you think about limited cost growth so how are the ACO's investments and programs limited healthcare cost and growth in the near and long term as you think about achieving scale under the model how do the ACO's payer programs and provider network impact scale as we think about improving quality how are the ACO's investments and programs expected to improve quality and what evidence do you really have for that future and then improving population health how do these population health investments tie specifically to these outcomes that we look great to in all-pair model. This is a reminder where we are in the scarce process so we're going to review budget recommendations and there will be a potential vote next week in January is when we expect to issue a budget order and then in March we'll come back for a review of final attribution and a revised budget as well as the payer contracts. So here's the summary of the public comments. We received 16 public comments between October 1st and December 11th from a number of providers and public individuals. So those are all listed at the top. The major things included primary care and social service providers saw a number of benefits of care coordination as well as population health investments and cited some of those specific benefits in their letters. You know some opportunities for improvement from FQHC and private citizens noted you know around scale how can we really make sure that we're expanding opportunities for scale outside of these hospitals which has been a primary focus and primary care and then there's been this consensus among commentators that we should review one year's budget critically and closely which we feel that we have and continue to do as we see more information. You know while this is an annual process we continue to monitor one care throughout the year through quarterly submissions and we expect to continue doing that. So we don't want you to think this is just all we have. This is an ongoing conversation in that process. And then you know a number of private citizens commented on three month care boards, some of their deficiencies which you know some of which we address through the budget and as more information becomes available like I said we'll continue to evaluate any information that may be relevant. Now we'll turn it over to Marissa for certification. My name is Marissa Melamed. I'm going to go through a deeper look at our certification review with you. The V-mount care board certified one care in March of 2018 after review and public presentation by the ACO oversight site staff is also included provisional certification in January 2018. A reminder that ACO remains certified unless and until its certification is limited to send it or revoked by the board. But the ACO must annually submit to the board an eligibility verification form which includes what you see on the slide that it verifies the ACO continues to meet the requirements of 18 GSA 9382 and this rule and then it describes in detail any material changes to the ACO's policies, procedures, programs, organizational structures, provider network, health information infrastructure or other matters addressed in sections 5.201 through 5.210 of the rule and that the ACO has not already reported to the board so we already include ongoing reporting and or by the submission as part of the certification review. The timeline for our 2019 review for FY20 we had the form posted by July 1. We received one care submission September 3. There were responses to follow up questions received October 16, November 22nd, December 2nd and we're here today to present to you our monitoring reporting conclusions. And then also we mentioned this already that in 2019 we first did our first eligibility verification. So due to considerable overlap in criteria between the annual budget review and the certification we've worked to align the two processes in terms of timeline and process review so you'll see that here. This year for FY20 we're presenting our certification review at the same time as our budget presentation to help align monitoring reporting requirements for the year so you'll see that in the same as the recommendation. So a reminder there are 17 statutory criteria in section 9382 for certification it translates to these 10 sections of rule five and I'm going to give you an overview of each section of our review for FY20. So sections 5.221 to 5.203 are concerning the legal entity governing body leadership and management. The way we've set up the review to make this clear in the public presentation is that the first column is the sections of the rule or the statute where that's applicable. The key criteria and second column is a summary of what's in the rule criteria and the third column are ongoing monitoring reporting so these are policies, procedures, plans, etc. that we have identified through our process since 2018 that are applicable to the sections of the rule and we collect these and review them as they are updated and we're going to figure out the appropriate frequency of collecting these but our forum always asks for the relevant policies and a summary of what has changed. The fourth column is our conclusions for our FY20 review and any recommendations for additional monitoring. So we are going to continue to collect and review things in the third column and things in the fourth column are new or changes that we've identified. So for the first several sections there are several policies that offer a review of 4-4 so they could be reported to us in January. We will collect those. This year we asked for resumes for the executive team. We've collected most of them I think we're missing a few. Under the solvency and financial risk section we currently review quarterly financial statements, the responsibilities of the finance committee and this year through our questions and responses and conversations with one care we are asking for more documentation of risk analysis and assessments submitted to be submitted to us under the section of the rules so we will work with one care figure. The next section provider network 5.205 again third column you'll see the current documentation that we collect and review. This year we have a recommendation for the network development strategy. We've collected this in the past through certification. We've identified some new or some specific elements that we want that to include that we collected through questions and answers and we want to fit to all of the report. You're going to see that in the budget recommendations when I go over the provider network section with you because we felt that fit well in the budget that's noted here. Same thing for the population health management care coordination section. We currently collect several policies and procedures. They are up for review. We will collect and review them and this year we are asking for a more robust monitoring and evaluation plan for community-specific population health investments such as the innovation fund and specialty pilots and again we decided that fit more clearly in the budget recommendations. So an advantage of aligning these is that you can see where the overlap was and this was one area. So you'll see that when Melissa talks about that section. 2.07 performance evaluation and improvement. Again continuing to collect the policies and procedures. We've noted that they have things that are up for review in Q4 and then again in Q1. In the patient protections and support section we have been doing twice yearly complaint agreements policy reporting which has been referred to the board publicly as well in presentations. We will continue that. We collect the beneficiary notification letters and in the fourth column we have policies that are up for review. We'll continue to do the complaint ingredients process and outline as well as review public comment as we always do that submit to the board and collect feedback from the ACO specific feedback through renown care boards advisory committees. Section 209 provider payment. There are more than a handful of policies and new ones have been developed that you'll see here outlining the ACO's provider payment policies and again we will continue to collect and review those as they are up for review. Under health information technology section 5.2.10 same thing there are policies that outline how they do the criteria and how they carry out their health information technology and do the analytics processes and we collect and review those. Finally you'll recall last year there were several new statutory criteria that I've noted the statute section they don't appear in the rule after the rule was adopted but last year you will remember we reviewed criteria for reviewing these new elements and the board voted on them. We identified reporting that we wanted the ACO to do which they completed for the first year and the third column and we're going to update those reports going forward for each of those sections and continue to request those. So this table provides a summary of our ongoing monitoring reporting plan. The first is kind of a large bucket one here will submit updated and relevant plans, policies, procedures, agreements, contracts, subcommittee charters and governing documents. These are all things you've identified through the review that happens quarterly twice annually or annually and we have to work that out between the board's aides and the way those plans operationally go through one care so we will develop a more detailed monitoring plan for collecting those. Financial statements are collected quarterly, executive team resumes would be upon hire. The new requirement for financial and legal vulnerability assessment would be annually and again that's going to require a little more discussion to figure out a section that would look like network development strategy is reported annually and has been reported with order one materials in the past. Same thing with population health care coordination and evaluation plan. Complaint and reuse information is semi-annually and the new criteria are reported annually as well. So this concludes the certification section of today's presentation for next steps we'll review any additional feedback from the board and the public will memorialize our review and memorandum to the board and then work to develop a monitoring reporting plan for 2020 in conjunction with budget conditions. Diving into the budget. So this is just a reminder of the statutory rule criteria for the budget review process. Through this review we'll look at historic and future expenditures, the effects of the care, the utilization of innovation services, and the data services. The ACO's efforts to strengthen primary care and social services, social determinants of health, childhood trauma, and then we think about reducing duplication of services and improve care coordination. We will also think about transparency costs, the effects of Medicaid reimbursement on other payers. We will discuss solvency and ability to assume financial risk, administrative costs, and then the character of ACO. So some of this again overlaps the certification process, which is why we're presenting both of these pieces today. So there are three main components of One Care's budget. The first component is the provider reimbursement. The second is One Care's administrative expense, which includes some kind of overlap with their population health, but then their population health investments are just $43 million. So as you'll see the bulk of this $1.4 million budget is really just provider reimbursements or funds that are already flowing through the system in the form of claims are now within flowing through One Care and can either be doled back out in fee-for-service or in a fixed perspective payment, which we'll talk about in the next slide. So again, so this $1,362 million or $1.4 million budget, the all-value-based budget, this means that One Care is accountable for all of these slides regardless of whether or not they're paid for in fee-for-service or on a fixed perspective payment. 35% of reimbursements are fixed perspective payments for estimated fee and 65% are estimated to continue on a fee-for-service basis. So as Sarah was talking about earlier, you can see that Medicare is roughly 40% of the budget. Medicaid is almost 21%. Commercial QHP is 12.3 and then commercial self-funded for 2020 is going to be around 27.4 given great estimates. So here we have a hospital breakout of fixed perspective payments. So you can see that it's growing over time and has almost doubled since 2018. We think this is a great venture to keep monitoring and have actually one of our first recommendations, if we go to the next slide, will be to expand this kind of reporting to other healthcare providers to understand whether maybe opportunities for scale, not scale, but to increase our fixed perspective payment. So looking at FQHCs, independent practice, specialist primary care, independent primary care and hospital primary care to understand where those opportunities might lie. We'd also love to see this information by a payer. So it's important to remember that provider reimbursements in this budget are only as good as estimates and attributions. So as Sarah has alluded to this morning, we will continue to talk about how these are just based on healthcare's estimates and that they will be final until the new year. However, we can still make a lot of, lay a lot of groundwork to understand how the budget might change as attribution might change. So we can say something about what we expect to happen and parameters around what we want their budget to look like, but we just want to keep in mind that this isn't flux. How attribution is determined is based on whether or not an individual has insurance for a provider that is participating in an ACO program as well as whether or not the individual attends or seeks care from a provider who was participating in a network. So there might be instances where you have insurance, but your insurance provider may not be participating, so you would not be attributed or you might have, you know, Medicare and it might be attributed, but the provider that you are seeking care from is not participating in a network. So these are examples of how you might fall into these different categories. And the reimbursement or the revenue that's going through One Care is determined not only by the number of lives, but also those lives historical expenditures. So that's how we abide that some of these estimates. So we'll go through care programs and put the provider network separately in more detail. We want to just first let the board know that these analyses are based solely on One Care's budget submission. We have not had the opportunity to analyze any actual orending contracts. As these contracts are still under negotiation, this is the same kind of situation that we've been in the year over here. And, you know, through this process again, we kind of talked about these contingencies with this understanding that we will have final attribution numbers and contracts for later date. And then we expect that One Care and the staff will come right down to discuss where that revised budget will fall. So to kind of give you a sense of the kind of programs that are expected for 2020, Medicare, Medicaid and Blue Cross Blue Shield QHP program are expected to continue with the addition of two new potential peer programs. One being Blue Cross Blue Shield Administrative Services Only or the large group program. The second being QHP program. As a reminder, you know, historically we have advocated that these programs should align a scale target or qualify scale target initiatives.  So having the possibility of shared savings for achieving goals related to quality and care utilization. The ACO of shared savings is a percentage of its expenditures and less than the benchmark is at a minimum of 30%. And if the ACO is at risk for shared losses, its shared losses is a percent of its expenditures and excess of the benchmark is at a minimum of 30%. Services comparable to but not limited to the all-parent financial target services and associated expenditures are included for the determination of these shared savings and losses. And the ACO's benchmark shared savings and shared losses for a combination is tied to the quality of delivery and the health of its aligned beneficiaries are both. So this is really just saying, you know, all these things have to work together. They can't just have shared savings and losses. They can't just have quality outcomes. These things have to be integrated for the system to work. So that's why it's important for these payer programs to meet these criteria. Of the existing and new programs we expect at this time that all the child continue to be qualified. As the auto market initiatives, we will reevaluate certainly once the final contracts come in and ensure that that is the case. In addition, there's also a requirement all-pair model for alignment across payer programs and alignment specifically to the Medicare program. So that would be on attribution methodology, quality measures, payment mechanisms and services including the determination of shared savings and losses. So this table outlines what we estimate part of one here is estimated to date where they will land in these negotiations. This was based on their October 1st submission, so these are still in flux. We don't have any information at this time on the new contracts, but across the existing contracts there seems to be greater alignment. The only notable differences which are actually exciting opportunities are in the Medicaid payer program. There's a conversation around geographic attribution which is interesting because it might be able to bring in greater scale and specifically those who may not currently be engaging with their primary care provider, so it's a great thing if it works and we hope to hear more about it as it rolls out. In addition, Blue Cross Blue Shield, there's no longer the pharmacy services including the financial targets, so now these are all in alignment. This describes the time rate, so I'm just going to kind of breeze through this because this is where Sarah spent most of the morning discussing, and I think we'll have more to discuss in a later date, but you know the point where the 3.9% for their primary care, 0.5% for Medicaid, 6% for their commercial QHP, 4.5% for their self-funded, for a total of 3.5% overall. There might be differences in how we determine the place experience versus how one care is done that we use CMS data in order to do that for Medicare and a number of other inputs for Medicaid, commercial, QHP, et cetera. But in all, I think what's important to know here is that the budget of PMPMs are roughly equivalent between what we've been estimating and what one care's been estimating, so the effect on the budget should be only small to others. So as Sarah said this morning, about 23.5% growth, Medicaid is currently estimated at 0.5%, but this is subject to Medicaid advisory rankings. We want to note here that this doesn't take into account the pricing, the 0.5% proposed by one care, which is held harmless under the all-payer model because we don't have that information to be able to make that determination. In the commercial QHP rates, one care said that this was derived from the cream-mount care boards, approved rates in the insurance rate review process, and we don't have any information on the self-funded rates at this time. So our recommendations around the payer programs are as follows. So first one, or recognition number two, the final payer contract plus qualified scale target initiatives, and they should align with that care on attribution, methodology, quality, metrics, payment, risk terms, services included in the financial target. So this is in line with 2019 budget recommendations. So we would like one care to come before the board on a date between one by both parties, but no later than April 1st in the new year to present on final attribution their revised 2020 budget based on that attribution We'd also like to see one care create a one pager on the benefits to self-funded programs of contracting with one care. And then if the geographic attribution methodology is implemented, we'd like to see the implementation manual associated with that. So we can learn more about how that is expected to work in a proper federal role. For the trend rates, we're just equilibrating what Sarah discussed this morning, 3.5% Medicare rate of the vote next week. Medicaid, what we do at this time, because we don't typically have the advisory rate case, is that we're going to recommend to doctor percentage within that range, but the subject to the Medicaid advisory rate case. And then the commercial QHP and self-funded language, we're just rolling this forward from last year given that contracts are still under negotiation. We'd like to receive actuarial certifications for each of the commercial plans, including self-funded benchmarks, stating that the benchmark is adequate and an explanation of how it's overall rate of growth across the years fits within the overall all-year target rate of growth and its overall rate of growth exceeds the target, how it plans to achieve a cumulative target under the all-year model agreement over the term. So if Jess has a question. Just before you skip to the next slide, can you just give us an update on the timing of the Medicaid rate case and the weekly estimates? Yeah, so they're currently working on it right now, I think by the end of the year, I have the Medicaid rate case finalist. Thank you. As a reminder, I'm going to go up with the provider network section now of the budget. As a reminder, the OneCare AC provider network is built on the foundation of participation by the home hospital. So this graphic visualizes 15 hospital service areas in Vermont, which includes 14 Vermont hospitals in Dartmouth, Hitchcock, New Hampshire, and shows increased participation in payer programs by these HSAs from 2017 to 2020. Just a quick plug, this visualization is available on our Tableau public website. If people haven't had a chance to check that out, there's also several other visualizations out there that the board's data team is working on to make information click by the board more accessible and available to the public. So this is a summary of the provider network changes from 2019 to 2020, as described with the OneCare budget narrative or as analyzed from the provider network table 2.1 that they submitted to us. This is the same information that OneCare presented during their budget hearing. I'm reviewing it here because we have received questions from board members, essentially that asking what does the ACO network look like compared to the full provider landscape of Vermont, so we want to be responsive to that with this review. So the question is in relation to both understanding how OneCare is building their network and in relation to some of the board's other work of mapping and understanding healthcare resources in the state, including providers and workforce. So this year, the network has expanded by the Norseville HSA to include Coffin Hospital for the Medicaid program. The Newport HSA has expanded into the Blue Cross Blue Shield, UHP program, and community health centers of Burlington has also added that program. So we've gained an HSA this year, three FQHCs, three independent primary care practices, naturopathic practice, three additional independent specialists, four independent physical therapy practices, one designated mental health agency, three new skilled nursing facilities, and an agreement with the ambulatory surgical center. We also looked at a reduction in the network, so Springfield is not participating in the Medicare program, they were in our programs in 119. We did an analysis of the provider network table 2.1, and I want to say this is a board analysis, we've not got this directly from OneCare, so I would need to validate it, but it appears that they have dropped five specialist practices in one primary care practice. Challenges that were noted in the OneCare budget, specifically you'll see this for the specialist practices that expansion to the Medicare program to the magnitude of the outside risk and operational concerns is a challenge they identify in recruitment of independent specialists due to lack of eligibility for incentives in the Medicare-based incentive payment system. This is another look and it's sort of an attempt for us to look at this question of what is the network like in relation to the total landscape. I want to stress that these are rough estimate numbers, some of them just came in yesterday, but we present it because we want to show responsiveness to this question and our evolving understanding of the full landscape of providers that we want to incorporate into this analysis. So we divide it out by hospital, sorry about provider types, so hospitals again we've seen from 12 hospitals last year to 13 of Vermont's 14 hospitals. This year federally qualified health centers, 9 of 12 FQHC entities are participating from 6 last year. Primary care practices is the ones that is the most estimated. So you might be tempted to do a proportion participating, but I would hesitate to do that at this time but we want you to see that this is something that we are working on. Data that I received from VDH yesterday is that there are about 267 total primary care practices in Vermont. So we have 76 is our estimate of included primary care practices that are hospital based and we got this from hospital provider directories online. One care reports and nine independent primary care providers participating and that's up five from the previous year and then FQHCs again this is data that I got from VDH, it might not be totally accurate but that there are 54 sites total in our estimate by the number of entities that is approximately 49 of those are participating. If any stakeholders want to help us with data we would welcome that. Independent specialists that I mentioned before what care reports that 25 are participating this is an area where from what we could tell from the provider table too they lost five and gained three and so this is a talent area as is mentioned in the budget submission and we don't have a good estimate of the total landscape of independent specialists. We have nine participating skilled nursing facilities is up several to 27 there are eight designated agencies there are 10 of 16 and in the other category which so far includes physical therapy in the Inulatory Cerebral Center we had one from this area participating last year and six participating this year and in terms of participation that table also includes whether they are participating in the full capitated payment or fee for service this includes providers that are participating move on here either through fee for service with accountability for total cost of care which could be on ranch take down in capitated payments or full AI community. On the next slide again this is just showing which hospital and various don't have representation in this group so hospitals are only hospital but very small and most of those patients are actually represented in other hospitals so there is essentially full hospital coverage federally qualified health centers we have picked up several however they are still unrepresented HSA's primary care practices we have good hospital coverage for independence there is room for expansion same with independent specialists for home health in hospice all communities are in the network for skilled nursing facilities there are using several DA's all communities are represented and in the other category there is room for expansion so the data I have shown here before I want to stress is preliminary work being done by the board the GMCB is working in collaboration with the Vermont department of health and mass provider landscape as part of the health resource allocation plan project task force which is working on this as well and they kindly let me put this graphic up here which is just to show what we are working toward this graphic maps all primary care practices in Vermont by type overlaid with FTEs for a thousand and in terms of ACO review we could also put an ACO layer on there and address that question of how well their network coverage is so this leads me to our recommendation from our analysis provider network information that we leave from the ACO budget and the certification materials we developed the following recommendation which I mentioned earlier with certification that we would like one care to submit their 2021 network development strategy to include the following elements so they've submitted this before this year we're asking for more specific things to be included so the first one is new and it's maybe going to take a little bit of working out but it's to include a definition for ACO network composition necessary to maximize value based incentives and this comes from conversation that's been had about what does network adequacy mean for ACO the term network adequacy is a term of art that applies to insurance companies so we wanted to still think about what that might mean for an ACO so we'd like to have that conversation and have it included in the plan provider outreach strategy recruitment and acceptance criteria their network development timeline have all been included in the past we just wanted to be specific about it we'd also like one care to quantify providers dropping out of the network and reasons why so that we can better understand the challenges to network development before you go to scale Marce I just want to point out that last night I had a conversation with a board member from the FQHC in Rotland they find it offensive that we always refer to them as chitchat and they would prefer to be referred to as community health so now we're bringing it back together back to scale so provider network and the payer program so what is scale since the percentage of the monitors attributed to the scale target ACO initiative this is designed to ensure that a critical mass of remodeled population is engaged in an all-care model and hence that providers have a real opportunity to change their care delivery and business models to support value not value and a migration from treating episodic illness to prevention so that being said this is largely tied to administrative burden as well so the longer that providers continue to operate in two systems they have to kind of think about how that might affect their business model so as we can see there's different targets for the all-care model and the Medicare scale target over time a year prior we are expected by our federal partners to reach 70% scale for the all-care model and 90% for the Medicare scale target this is just some background we've probably seen this slide before that talks about the different populations relevant to the all-care models we have remodeled population of the population used to determine all-care model scale so it's a total possible scale denominator as well as the total cost of care denominator the GOBE decision is about data reporting by self-insured populations so that's why that came down and then there's this notion of ACO attributed versus non-attributed and then the ACO Medicare life so these are all nested populations and we just wanted to kind of call out that it's important to understand what we're talking about when understanding different pieces of the model so given one-cares budget we wanted to provide some estimates of where we expect scale to land as compared to prior year so they have indicated that they expect approximately 53,000 attributed lives in Medicare this would be a slight drop from last year in Medicare population Medicaid would be an estimate for their budget for commercial self-funded 66 commercial fully-insured by almost 36,000 lives this is for a total of almost 250,000 attributed lives which is an increase from prior year so maybe not for Medicare but for some of their other payer programs in response to not being a scale target before conducting a survey over the summer mainly with hospitals and FHC partners to identify barriers to scale and potential strategies that the state our federal partners and the ACO as well as local partners could pursue to improve scale and experience with the model in general strategies that were identified through this survey fell into two broad categories the first being around unit structure and that it should be more transparent the second that payments from the ACO participating payers must offset the additional administrative and reporting requirements so this is the administrative burden that we mentioned earlier incentive money is a delivery reform with a greater emphasis on prevention and health improvement so we want to work towards population health so a lot of what we've heard is in line with expectations of excuse me, the all-pair moral agreement I think they just advocated for some more nuanced ways of how we might look there so this brings us to well, first we'll go through some examples of what these partners identified as next steps for one care so some examples include designing an option for primary care to join the model without the hospital partner offering multiple risk models based on hospital size and readiness improve clarity of contracts with F2HCs expectations that will hold access to mental health offer a facilitate network-based health opportunities to smaller providers continue to improve care and applicator to allow use for all patients not just ACO-attributed lives and reduce burden of duplicate records in violent uploads for existing EMR system so if you're an administrative burden they've made significant progress on some fronts there's always opportunity to pursue that further we've posted the scale target memo I think when it initially happened on our website we've included it here and so part of our recommendation we'd like one care report formally on the status of their scale target memo follow-up items during their presentation on final attribution and revised budget so that honor before or before April 1st by now we've alluded to earlier I just want to make a very quick comment to go early in our relationship to Medicare because we had also had an analysis presented to us from Sarah Lindberg a while ago now I don't remember when exactly which when she looked at the Medicare attribution methodology and this actually might be in the scale memo what we have learned since the negotiation of the agreement is that it's not it's literally not possible to reach the 90% Medicare target because of the way that Medicare does attribution which is not something that is state specific to our model so I think it's just important to remember that that the scale targets that were negotiated didn't have the benefit of that detailed attribution analysis but it's important to remember that we already know we're not going to get to 90% the way that Medicare does attribution and it would require a change on Medicare's part in order for us to get there. That's absolutely accurate. Thank you Robin for reminding us and this was also evident in the June scale target report. Thank you. Now we're going to talk about the model of care and the population health investments. So this table is actually taken from the 2017 population health plan that was produced at the end of the SIN project. We were writing a report from the legislature recently on the integration of social services within the ACO and the progress that's been made thus far and it provides a roadmap for where Vermont and the stakeholders wanted to go. In the first column we have what's called episodic or non-integrated care where we would have a lack of coordinated networks, lack quality and cost performance transparency and or the coordinated and chronic care management. So in our conversations and analysis we now are falling squarely into delivering outcome based accountable care that's person centered with focus on care management. One thing that we noticed during the process of this review is that the state agencies are working with the ACO to implement population based strategies and those are that's how we're going to get into the 3.0 category. I know it's a little hard to read but some of the things in that category include healthy population centered care not just person centered care population health focused strategies which one here and the networks are working to coordinate population based reimbursement right now we're doing value based reimbursement and next step would be population based reimbursement and then learning organizations which one here has been working toward at the local level that are able to deploy best practices that they're learning from their data. So it was a fun trip down memory lane. This table is actually also from the SIEM population health plan. In our slides the that's for the accountable care organization list. Then going over we have the agency of human services and the director of health care reform. The blueprint for health. The green mountain care board and additional stakeholders that are then working with the community collaboratives which are all out in the 14 communities and were developed by the blueprint. The green circles going around are all the providers that one here is working with and that are working together to improve population health and value based care. Some of those include the home health agencies and the hospitals and the SASH. So it's important to remember that there are a lot of stakeholders out there working on this reform especially as we're doing our own review. They then work on community priorities which they've identified themselves based on their own data and community needs and what they would like to respond to in that community. So running that needle forward one of their role is working with the state-wide network of providers in the quality of care while reducing the necessary costs. In our review we found that they were doing this through two major ways. They're supporting that state-wide care transformation and payment reform network and activities that are happening at the local levels and some of the examples are not inclusive but of the work that they're doing is they're coordinating with the blueprint's community health community collaboratives to identify gaps in care and use data to perform improvement activities. They're providing plain data for these collaborative providers to work on utilization costs and quality. They've built up the Care Navigator tool that Elena just referenced which is an electronic online platform for all providers or for care managers to use in order to communicate with each other around complex patients. They're also working with negotiating care contracts that are value-based and then also developing and managing the fixed payment methodology. The second case which I'm going to dive into a bit more next are the payments and community-based new initiatives for population health. Some of these payments support daily efforts in primary care and then others are to fund new innovations with outcomes for potential breathability. This shows where the population health investments of one care fall into. So we found in our analysis that 70% of their payments are actually tied into their care contracts which means that there are deliverables in those contracts that one care is accountable for. Some of those projects are listed there and they're also listed on the next page. But they include dual-save which is a childhood resilience program, Rise Vermont which is a prevention program. They have per member, per month payments and a comprehensive payment reform program and like I said I'll go into them a little bit more on the next slide. The next section is the Medicare funding for the blueprint for health programs that was talked about earlier this morning which has grown from 7.7 in 2017 to 8.2 million due to our regulatory responsibility and work with CMMI and that supports that goes directly out to support the SAASH program, the community health teams and the blueprint the Medicare portion of the patient-centered medical home payments. And then finally we found that about 10% fall into the community-specific projects which one care is funding. Some of them are in an innovation fund and then some of them go toward pilots with working with specialty providers to bring them more into the continuum of care. This is one of those projects from the last page by the same colors and the categories of investments that we found. So a large portion of them fall into primary care investments and they're also investing in quality care coordination prevention and then as we mentioned the blueprint which are all of those things primary care quality and then care coordination and then finally some of the innovation funding at the bottom. So what we found for 2020 the main changes that we found in the population health programs fell into three categories. One is that they'll be putting money towards additional innovation projects which is determined through their process and through their population health strategy committee. Then they also determine that they're interested in embedding clinical pharmacists in primary care and the evidence shows around that that pharmacists in primary care can help to lower health care costs improve quality of care and increase patient satisfaction since pharmacists are often not in the medical setting but a planageable role in providing that integrated care. And then finally the bottom one is they're making some changes to their complex care coordination program where they're going to be increasing the payments to providers. That I'm going to go into the next slide. So what the complex care coordination program is are payments for providers. The providers that qualify are primary care, home health and the designated agencies who are providing care for high risk and very high risk patients as identified through one care data. And on the left are the care coordination payments that were provided from 17 to 19 for these types of providers. They fell into two major buckets. One was providing care coordination just based on deliverables that one care has in their contracts with these providers. And the second bucket is it's called patient activation. So every patient needs to have a shared care plan so that everyone knows what that patient needs and they can use it for a communication tool and it lives in a shared care as previously described. One care was that they weren't achieving the activation rate that they were looking for from patients. They were at about 7% in their measurements and complex care coordination has been shown to reduce costs. You know, you were getting your patient to the right care at the right time. So based on time home meetings and stakeholder feedback, their network decided to try out a new model along the right. So they increased that per adult life or per member per month payment to make sure that a patient has a shared care plan in care navigator and that they're paid monthly on that.  Anyone who is designated as the lead care coordinator by the patient is receiving $80. And then secondly, they're required to have a care conference which brings all of those providers together. And so it takes a lot of effort to get everyone to the same page and make sure that that patient is getting what they need. So those lead care coordinators, I would say that agency receives $300 once a year.  These numbers for our conversation with one care were derived by the network to allow for care coordinators to actually hire. The prior PMPMs weren't quite high enough and so it wasn't allowing the infrastructure necessary at the local level. Can I ask a clarifying question? Certainly. My recollection is that the lead care coordinator is chosen by the patient. Yes. And my other clarifying question is actually that was it. And so to bring that to a local level I might be working, if I'm a patient and I have a primary care doctor and I'm also working with a designated agency and I might even be enrolled in Home Health I would get to choose where I want my lead care coordinator to be. And based on the data that was provided to us, a majority of them are still in primary care. But some patients may feel more comfortable being coordinated by someone with their designated agency or Home Health. So we have several recommendations that we will go into in a little bit but we wanted to unpack a ratio that we've been using to measure the investments in population health over the past several years with one care. We applied this in 2018 when we first reviewed their budget. So what this ratio is, is basically the population health investments we can take the final column which are budgeted at $43 million and put that over the $1.4 billion. That brings us to a ratio of 3%. Last year that ratio was 4%. It's directly written by the amount of dollars that are going to providers. And because we don't know what that attribution is yet or the final contracts we would like to last year we had. So last year this was our requirement in our 2019 budget order that they must fund the PHM so it's currently still this year that they must fund their population health investments at no less than 3.6. So we gave them a variance of 0.5 from the 4.1%. And that they must fund the cash and the blueprint for health investments at the Medicare level plus the inflationary rate of 3.8% which we gave them last year for their Medicare benchmark. And then if these percentages were less one hair needed to promptly alert the board to this. So we're envisioning something like that but we don't feel like it's time yet to put a final ratio on that. So what we are proposing is that we receive their final pair contracts the final attribution numbers one pair providing an analysis for the board on each population health line item to determine whether and why they're scaled appropriately for attribution or some other factor when we receive their revised budget in the first quarter of 2020. And then these are the recommendations for the population health investments which I can read but small. The first one is exactly as we just said that programs are not fully funded as detailed in the 2020 budget one pair will be putting forth a revised proposal for the board. In terms of monitoring we're looking for the population health investments to be recorded by the health service area quarterly and by program and by different provider types to see what that distribution of dollars are. And then we're asking that one pair use their community specific population health investments to the innovation fund and specialty pilots to address cost and quality differences across health service areas as identified in their variations in care analyses. And these investments shall be evidence based be assessed for return on investment and be tracked by the ACO. The next one we were talking about certification that we're asking one pair to develop a work plan to evaluate the effectiveness of any population health investment and this includes how they can scale those that are successful how they might sunset those that are not and then report on opportunities for sustainability of these programs. So this plan could include what is not limited to the tech of entity, the funding, the evidence for the funding, the distribution plan so basically just a robust work plan for each line item. And we would expect that this be submitted to the board in the first quarter of 2020. And then finally we would like one pair to provide a mid-year update on the 2020 complex care coordination program which would include data on enrollment payments and any challenges or learnings that they have found from this change in their complex care coordination program. This would I'm saying mid-year, it does not start until April 2020 so mid-year or the third quarter whatever makes sense and we would want one pair. So I'm just going to give a pretty brief overview of the process for measuring and reporting on quality performance and I'll highlight some aspects of Rule 5 which you've heard Marisa talk through and also just a reminder of what we're responsible for through the all-fare model agreement. I know we're specifically here talking about ACO budget but it's hard to disentable those things in some of these instances. So just a quick walkthrough. And as a reminder and you heard Elena and I talk about this on the 20th when we were part of the panel presenting on one pair's 2018 quality results that there are separate requirements for reporting for the all-fare model agreement and the measures for which the state is held accountable and then the measures for which the ACO is accountable for through their pair contracts so I just want to make that clear. So this pair, just a reminder of the requirements through the all-fare model agreement and again I have a citation from page one of the agreement that I was going to read through but it's quite long. So then I'll just talk about what's required through the quality report that's included. So first we have to talk about the process on the quality targets and as a reminder we've got 20 required measures as per the agreement and that one monitoring measure that we are currently working out with our DEVA team our friends over at Medicaid to figure out what the best sort of measurement for that is moving forward and that's the proportion of folks receiving care through a specialist and it's an access measure specialty versus primary care. The second through the annual quality reports that we have to focus on is how scale target ACO initiatives hold how much ACO is accountable for, quality of care the health of their line beneficiaries are both. You've heard Elena talk about that they'll probably hear you repeat it at Nazian between now and the end of the agreement and the third thing that we need to talk about is how the state holds Vermont ACOs accountable to allocate funding for and invest in community health services to achieve those statewide health outcomes and quality of care targets. As a reminder for the corrective action triggers in the agreement we need to meet four out of six of our population health outcomes targets, four out of seven of the healthcare delivery system quality targets and five out of seven of our process milestones before we would hit a corrective action trigger for any of those specific sub-categories. And then a reminder through rule five, and I talked about these earlier so I just wanted to give a quick highlight so there's also requirements obviously through rule five specific to the ACO and so here a couple of expert that outline some of those requirements so first is the provider network ACO's participant selection criteria must relate to the needs of the ACO and the role the population inserts including access to and quality of care although everything that's emphasized out here is not like that as a rule. The second is 5.206 that's the population health management and care coordination section of primary function of the ACO is to improve and roll these quality of care by enhancing that coordination and management of services they will receive and this is just a summary of section 5.207 it's the most needy section of quality requirements in the rule and that's the quality evaluation and improvement section so just some highlights it requires an ACO to have a quality and evaluation improvement program that identifies problems in health care delivery and opportunities for improvement evaluates the care delivery to patients against defined measures and standards and must utilize evaluations to provide feedback to participants to improve quality of care. We might have forgotten to talk about these around slide so a couple of things we just wanted to highlight so as I already mentioned we had the ACO come and present with a pair of programs their annual 2018 quality results on November 20th that process will continue annually as results become available from the pair of programs and second the 2018 all-pair model results will be presented by GMCV staff when they become available as a reminder from the 11-20 presentation the quality results are annual so 2018 as you recall is the first year of the agreement so we won't be offering any trend analyses in those reports it will simply be the results of 2018 until we get the 2019 data in the books which will be around this time next year that's when we'll start to produce some more analyses on results over time also as a reminder while some of the all-pair model measures are the same as some of the ACO-pair contract measures they're not all the same and so there have been questions about where we'll be able to identify the ACO population and where we won't so I think that will come into play also so for example any of the population health measures and survey data so from the behavioral health books factor surveillance system we can't figure out who in that population is attributed to the ACO or not and so that measure will always just be consistent over time and that trend will not be broken down by ACO and not ACO participating in terms of next steps we will be analyzing quality performance data and results that become available and again we're not going to be able to look at all of the required measures through the all-pair model agreement by ACO and not ACO participating and the second is per the requirement of agreement we'll work to develop a policy for ACO regulation on quality performance in alignment with that requirement of how the state holds funding and investment community health services to achieve those targets that are outlined in the agreement can you just remind us when you think the timeline of that is roughly? the all-pair model final when you think you'll be presented so what I am currently working through with our federal partners is a conversation on producing the data that we do have by the end of this year reducing a supplement to that report or if it's preferred from the federal government that we wait until we have all the required data so if the latter sometime in January it's likely that I'll be presenting to the board early in the year and part of that has to do with any of those claims based measures that we needed to wait for one out on to be able to appropriately calculate we wanted to make sure that it was done accurately and so as Sarah mentioned earlier we're just starting to get that final data in so while hopefully moving forward it will always be done by the end of December this year it's a little bit of an exception thank you so one pair is administrative expenses so in total these are around 19 million dollars proposed for 2020 61% of this budget goes to salaries and benefits about 19% to software and the rest you know services rent, other things like that what's important to note here is that I think it was evident some of one pair's presentation is that this is not all just administration of one pair it's also some of this salary benefit actually goes out and serves more clinical and coordination activities so I think in the future we'd like to kind of parse this out a bit further I just wanted to make a note but we are looking at the total salary our total administrative expenses so it's probably not such a status how it's been calculated to date is looking at ACO operational expenses at 19 million over the ACO's total revenue operational expenses includes like we mentioned previous slide salary benefits contract supplies was not included is population health investments are this idea of existing health care spending so this is the measure that we've been using since the beginning and we'll continue to use for further purposes if we look at how this ratio has performed over time or how the ACO has performed over time on this ratio in 2018 they landed at 1.8% of their budget and then the proposed budget for 2028 is down to 1.35 so while their administrative expenses are growing in aggregate over a prior year it's 21% for 2020 the administrative expense as compared to their overall budget and the dollars passing through the organization is actually decreasing so having said as we mentioned before there are a lot of elements still in flux that might affect this ratio so we want to try to take apart realistic scenarios of swings that could occur with attribution and funding that might affect where they would end up and we still feel like 1.35 is pretty robust to some of these swings on the left you'll see we call it the low growth of assumptions about available funding and if they're decreasing attribution and we still calculated 1.6% administrative expense ratio under high growth conditions if they were awarded the funding and they had this growth in attribution you never might still look at 1.2% 8% of the budget so if we this is our recommendation number 14 if total revenues are projected to increase the administrative expense ratio shall not exceed 1.35 if total revenues are projected to decrease administrative expense ratio shall not exceed 1.6% unless otherwise approved by the board and then we wanted to reference this before and we'll review this condition upon final attribution so if there are really dramatic swings beyond kind of what we did to some of these assumptions that we would visit at that time there are no questions on administrative expense will continue to serve so while they're this is kind of a broader discussion working with contractors to think about risk and reserves at a system level and how we might think about this across our regulatory levels so this is kind of we still have work to do here but wanted to share some of our thoughts that we've been developing so to review the different types of risk flowing through the system so the first is insurance risk so this is the financial risk that is based on prevalence, severity and types of health conditions that occur in the population and performance risk so the financial risk based on what is done to mitigate those health conditions so this performance risk is really affected both by the ACO and the provider and also by the population's willingness or ability to access those services so the key takeaway is there's kind of this overlap between these types of risk but that you know both types of risk can be measured and are transferred in this model to the providers and here are our providers and in this model those providers are in the hospitals who are bearing the majority of this risk alright so the percentage of financial risk transferred to one care varies by payers as a percentage of total health care spending payers transfer approximately 3.2% of all care aggregated financial risk to one care the remaining risk resides with each individual payer so the system level is only 2% so we just wanted to highlight that for you and then of the 27.3 million of Medicare that's 5% of Medicare expenditures that one care projects at risk in 2020 is being transferred to the hospitals and then if you take into consideration their risk free insurance this drops down to $15 million or 2.8% of Medicare funding and as this flows through this affects the total bottom line reducing the overall risk to 2.3% this is just a visualization of the relative amount of risk by payer to the total revenues so the dollars at risk are not at risk so you can see that Medicare and Medicaid are finding the leaders in the amount of risk that's being proposed but really it's still a relatively small portion of the overall volume this is another way of looking at it that was the third party risk insurance so it's really 28% of the Medicare risk or of the overall risk it's a large chunk of the Medicare risk and it kind of shows the relative magnitude of risk by payer so while the risk bearing entities are individually at risk for the amounts to $144 million the impact of the Medicare's work the insurance means that the hospitals will have access to this risk pre-insurance to mitigate their total risk exposure so it's right here it's shown in aggregate that these dollars would flow back through the provider network depending on the magnitude and what actually occurs so at a system level it's 32.8 sorry, 35.8 if we look at hospital maximum risk limits we want to point out first that there are three hospitals still in the risk communication strategies so this reduces the total amount of risk down to 40 million from the 44 and then we looked at days cash on hand and MRL is the percentage of days cash on hand we can see how much I'm seeing it breaks up but this kind of breaks up percentage of the system level relative to there jump into the risk model could I just ask a question so I think it's helpful to have the risk as a percentage of total healthcare spending but since the hospitals are taking on the risk for all providers in their community it would also I think be helpful to show it as a percentage of the hospital spending because even though it's a relatively small percentage of the overall spending for the hospital taking on that risk for every other provider I think it would look differently compared to hospital spending so having maybe that lens would also be helpful just to put it in perspective to add to that Robin were you asking for it as total NPR the hospital or total NPR they receive from the ACL I had been thinking about it as total hospital spending just because that mirrored like the previous slides but I don't have a strong preference so I'm excited for you I think having it both ways just as a percentage of their total NPR but also as a percentage of the NPR that they're the FPP that they're getting from the ACL because we see that will change for those hospitals that have more of their patient care being done outside of that hospital it's a higher percentage I wanted to call your attention that one care to risk model has changed since FY19 as the founders are now assuming hospital specific risk mitigation approximately 3.8 however one care noted in their submission that they would like to retain the $4 million in reserves for specific hospital risk mitigation arrangements for general quantity concerns we asked them to quantify this but they did not receive any quantification of why this $4 million was the appropriate amount so we just wanted to bring that to your attention so our recommendations here are that any further changes or developments to one care's risk strategy must be documented and presented to the dream lab care board including the reason for drawing down reserves and in addition to that these visitors will be limited to population health investments in supporting participation in hospitals engaging in sustainability planning unless otherwise a group by the board this one would be new for last year so finally I think we've not caught a valuation we're almost there so evaluating all care model and the ACO is the vehicle for all care model so under the all care model hearing out care board reports on scale cost and quality or total cost of care and quality through these specific deliverables outlining the model in addition to these required reports staff, the board will leverage internal and external sources to dig into understanding incidence trends and scale cost quality utilization so that means that we can get reports back from our payers like we've just had this in the past few weeks in your results in 2018 so we're going to be triangulating across a lot of different data sources and a lot of different inputs to kind of understand how we're doing as a state so an example of some internal reporting that we have to look forward to is primary care spending by payer and then we'll be looking at how to perform this relative to the broader permut population and we could go on and on there but we'll just for simplicity's sake so our recommendations around evaluation we do an internal reporting with primary care to develop a performance dashboard to be heard by the board by the end of Q2 including implementation plan and that implementation plan to publish that performance dashboard in addition as I've mentioned we have work going on at the board but we wanted to memorialize our commitment to developing and publishing a dashboard comparing ACO to non-ACO or overall Vermont performance and the dashboard to reflect current and actual trend data analysis on the following topics, quality utilization to local health care, attribution by payer percent of fixed perspective payment versus fee for service for metrics tied to all care model and perhaps population health measures so we're looking at other stakeholders in our Vermont state partners that we could work with to really make this a robust exercise. Can I just ask a question? Certainly. So maybe Melissa you could just give us a brief update on the federal evaluation so that we should understand there's the work that we're doing here and I know you're thinking that on the state side you could just share the board and the public where we are on that. Yeah, Sama Mai has hired the University of Chicago N-O-R-C as their company name and national I'm not exactly sure what it sounds like they want to go by N-O-R-C they don't want to go by the full spelled out so that is their name I think it's a national community research company or something like that so they are doing the next generation evaluation as well for CNS and have been hired by CMMI to do the all care model evaluation we've been working with them to set up the first year of their review we've met with them they will be doing a survey of providers both ACO and non-ACO interview and are working with stakeholders to distribute that survey as well we are waiting to find out when the final first evaluation will be published it's now sounding like late summer of 2020 due to data delays what we're finding in this model is that data is something that is not always expected as we would hope to get into clean speeds and everything else so we want the data to be right and we'll be working with them in the perpetuity of the model and they have a very robust plan for evaluating the entire model with a comparable population and as soon as the plan for evaluation becomes public we plan on sharing that more broadly can I just ask the following question that I know expects you to be able to answer but I'll put it out there so you can send it over to them I think one question that will come up is how they're going to account for the blueprint for health impacts in the non-ACO attributed population because the blueprint has a favorable evaluation showing savings compared to a controlled group so I think that has to be factored in some way because the ACO is required to build off of the blueprint so we now have this kind of embedded care coordination model that the ACO is working with and kind of integrated with um untangling that seems complicated but I'm confident that Nor can figure it out I just want to make sure that they're thinking about it we can provide their plan to us which is still an internal working document their internal working document but if they describe the history of health care reform in Vermont and are definitely taking into consideration the formation of the blueprint and the same project in relation to where we are now with the ACO model and we'll mention this as well so like prints it's the National Opinion Research Center and they wish that to be the formerly known as that's like it's the North formerly known as I think AARP did that too whatever AARP used to stamp so here we just wanted to you know a lot of the recommendations you've seen today are similar but different than what we've proposed in the past we would like to carry over some recommendations from 19 that have been discussed explicitly and I'm just going to list them here some of them do overlap but A through F K then through S so when we come back next week we will have kind of specific we'll have reconciled those we didn't have time to do that here but we hope to in the future by this day that they're all explicitly laid out so I think we'll be hearing forward to seeing a number of recommendations from prior here and I'll just send them to meet some of our new proposals and I'll like to coal my Q budget order for public consumptions and on this slide so we're back to the summary of our recommendations I won't read them again but they'll be here we need to reference them of conversation. Other recommendations we'd like to point to include just additional deliverables we would like to see from one here, especially hospital dues for 2020 by hospital, 2020 population health management sources funds by payer by hospital, the hospital risk addendums, and then if funding, DSR or APD funding are granted, what are their planned use? And we expect this to be part of that conversation in Q1. Delivery system, reform dollars, and Robin, help me, and I, APD, I don't know, I don't know, I don't know, I don't know. Okay. What goes your after? It's the technology money for Medicaid. Okay, thank you. Sorry. So next steps, so the board will vote on one here every month's budget and then for a benchmark growth, which is scheduled for next week. Green Mountain Care Board will then produce the FY 2020 budget board for one here. Then staff will update our ACO monitoring plan. Green Mountain Care Board staff will continue hosting quarterly ACO monitoring reporting materials as we've been in the past. And we expect, as Michelle mentioned earlier, for staff to present on all care model quality results in early 2020, one care per month will then provide a final care contract, final attribution, and revised budget to the board by April 1st of 2020. Then our first annual report on all care model will be published to people as I said, end of summer, but maybe fall 2020. And the Green Mountain Care Board staff will continue to update the board on development of ACO performance dashboards as that progresses. And we'll also keep in the loop on the Medicaid advisory rate case and the 2020 Medicare contract. And we'll note my excuse, those are publicly available. And in addition, staff will continue to meet regularly with the healthcare advocate, which has been very helpful in kind of finalizing our recommendations or this ground for recommendations and identifying our opportunities for our community. Regulatory integration, I think historically we've had this conversation. We were going to, because of time, kind of hopes to have this in the future, but there are certainly a lot of opportunities. I think we've alluded to them along the way in our presentation. You know, Green Mountain Care Board staff have already been identifying process improvements and opportunities for late regulatory processes. And there's one people that some of the board members and staff are working on actively. And then we've also are looking forward to working with the healthcare advocate to further identify opportunities to link inputs and outputs between our regulatory processes. And due to the depth through the content we have today, we won't go explicitly, but we'd love to come back and present more holistically and bring those great integration opportunities in the spring. So now we're ready for questions. You can take a deep breath. Questions from the board. Tom. Roll through to the beginning here. I think this is an easy one to answer. Is that on slide 19, there is a kind of the key criteria column, solvency and financial risk. That's soon that just means ACO, solvency and financial risk. The rule, yes, the rule is about ACO. Moving forward to slide 22. I'm looking at the. Let's try to put it up on the screen so that everybody can find the room. Yeah. It's just going to take a minute. They have to go through all the process. We've got a long way back. Yeah. Well, I'll talk slowly while I ask my question. You know, on that slide, it has to do with sort of case and eligibility verification. And part of this is population health distribution procedure. And I'm just curious in terms of that $43 million. Is there any requirement that a beneficiary of it provide matching funds? And the reason I ask that is that I don't. Sorry, Tom, can you restate your question because we have a lot of technical. Okay. In the distribution of the $43 million in population health investments, as I look down the list, I saw attribution as kind of one of the kind of drivers of that distribution. But I just want to know, I'm concerned that it's not a level playing field out there among providers and some can take more risk and others and maybe even in engaging in these population health measures. And so if there's a matching requirement and a provider that would really benefit from these investments might decide not to engage it just because of the matching requirements. So I'm just asking to do, does the ACR require a match, a financial commitment to these investments? To the population, not to my knowledge, I don't know any matching requirements. Thank you. And with our current analysis of the population health investments, it falls into two major buckets. They are either payer dollars or hospital participation fee dollars. That's about what people are doing. Turning to slide, just like it's 26 again, I can talk slowly here. This is under budget process and we're looking at the broad categories. And one is the effects of Medicaid reimbursement on other payers. But I didn't see any further discussion of that through the slide bank. And I'm just of the view, let me know that the payer mix and Medicaid cost shift are structurally flawed profits within the existing system. If you step back and say, what would the landscape of healthcare look like if there was no cost shift, the payer mix was equitably distributed. The benchmark plan was up to date and the hospital budget process led to a more playing field in terms of the distribution of operating margin. So I'm wondering what the further thought is on this bullet which says effects of Medicaid reimbursement on other payers. Yeah, I think there are a number of ways we can look at that through other reporting mechanisms. I think it's an ongoing conversation and it might be a regulatory integration. But I think it comes up. We also have the peer differential report under the all peer model, which is that there's different times at which this will be presented. Mr. Lurkin, on that report on this year, the peer differential assessment will be first and then there'll be a number of reports next year that will get at that in a little more detail. Because I do worry, I mean, I am a supporter of the ACO and I believe we're on the right track. But if there are these kind of structural imbalances that exist in the seams between Green Mountain Care Board and D.Va and the ACO, et cetera, I think it would be a mistake to kind of not address those and to find a path on which to address them. Looking at slide number 45, the provider network. And I work with this whole section on provider networks. I just don't think it's accepted well enough out there that this is a voluntary system. And we have dozens and dozens of providers that are now engaged in this system and associated with each one of those providers or collectively with those providers are thousands and thousands of Vermont are sitting on hospital boards on designated agency boards, et cetera, et cetera, trying to figure out on the front lines of healthcare what to do. And so when you kind of follow the money associated with that, you can see that these entities are kind of voting with their budgets and these are budgets that are embedded in these local HSA communities. This is, you know, this is Vermont at its best to a great extent. And so you follow the money and you have total revenue of the ACO at $634 million in 2018, $881.9 million for 2019 projected and $1.42 million for 2020 projected. And I just think it's important to note that the providers that are engaged with the ACO are doing it on a voluntary basis. This money is their money and it is safer to them and to their operations. And there's a lot of wisdom out there at the local level. And I just think that looking at this list of providers and the growth that you're experiencing is something to be recognized and underscored in this process. I thought I saw at some point, I'm on slide 77 now. I thought I saw at one point that there was a requirement or calculation on showing that the net savings of the positive savings versus losses, the net of that kind of being a measure of the value of the administrative expense associated with the ACO. So over time, is that measure, am I, it's my memory? You're accurate. And that is one measure that we proposed to carry forward from 2019. It's been there for a number of years. The challenge with this measure is going to be about how we quantify some of these things that are really qualitative concepts. So for gone spending, there's really no way to, well, I shouldn't say no way. It's very, very difficult to quantify something that has not happened. So there's a lot of assumptions made into there. So I think we need to, with the broader group of our stakeholders, really understand what it is that we're trying to understand and measure and what is the appropriate way of assessing value. Because I saw in one of the comments to the board that this is just an added burden of administrative expense. And I thought that was a fair question. Because in some degree it is, this is new. And it's a could be viewed as a burden on the system. But really, or it could be viewed as an investment on the system that we have this kind of loosely fit together infrastructure and healthcare in Vermont. And this is bringing efficiencies to that system as well investments that make Vermonters healthier so they don't need the system as much as they might. So I would support that comment that we find a metric that basically is simple and well and understandable that says, yes, the administrative costs of the ACO are of a value less than the savings that they're bringing to the system. And I think the challenge will be in identifying a metric that might be a series of metrics or a metric in a conversation. But I think the staff would hope that the board would recognize that there are a lot of qualitative measures that are really important to consider in evaluating the value of this model broadly. And under my last comment or question, Orina is on regulatory integration. I mean, as you know, I just think that that's an important thing to do. And the areas clearly are having to do with pay or mix, having to do with the cost shift, having to do with the benchmark plan, for example, I think in terms of the ACO, looking at the benchmark plan, Blue Cross Blue Shield's 2018 expenditure on QHP or revenues in terms of QHP premiums is $340 million. That's about 25, 26, 27% of the ACO's entire budget. Yet the QHP plan is dated back to 2014 before the all-finger model. And so just finding a process, a regulatory process to update these, to make things move forward and sink is I think an important undertaking. My final observation has to do with a condition that we put in the 2018 budget, I think having to do with asking the ACO to cooperate with the board to develop a path to that moves any savings out of, into commercial insurers and into the pockets of repayers. And because there was no savings, it's a kind of a moot, I guess moot, moot issue. And we've moved on. I think that this is an important issue to address in terms of looking at the relative balance of say operating margin between an insurer like Blue Cross Blue Shield and their ability to push money downstream back into the pockets of repayers versus other parts of the system. And I'll just give you an example. Over the last four years, from 2015 to 2018, the total premium revenue of I've got to care somewhere of Blue Cross Blue Shield was $2.16 billion. It's a lot of money in terms of the healthcare system. And most of that got paid out in premiums that their loss ratios are quite high, maybe too high. But of that amount of revenue that came into their system, over that four year period, they had two years where they had losses and two years where they had gains. And the cumulative value of that was a $3.4 million gain on $2.16 billion worth of premium. And I just don't see in that scenario where there will be any reasonable expectation going forward that funds can be pushed back to rate payers given the way the system operates now. It just doesn't work. You look at another arena where money in the healthcare system flows and the UVM Medical Center is, at the other end, at the other end of the spectrum, where over that same four years, they've experienced $264 million in operating margin. That's not total margin, that's operating margin, and which is 5.6% of their revenues. And I think the expectation that was in that condition O is still valid. We need to find a way to solve some specific problems like the premium cliff at 400% of poverty, which in my view is not a big problem to solve if people want to do it. But the more structural problem of how operating margins or the margins kind of move in the system so that the smaller hospitals don't run into the wall of solvency and rate payers can truly say this system is working for them. And it means that their co-pays or the deductibles of their premium are not trending as they have trended in the past. So that's kind of my hope for this regulatory alignment that you have here. I think we'll look forward to connecting all the dots across the processes when we can come back together this spring. I think there are a lot of layers between the ACO budget and the insurance rate review process that we have to understand in a more nuanced way before we can make more precise recommendations. But thank you for your comment. If I could just respond specifically on the regulatory integration as one of the board members who's been working on that, we've been focused on Green Mountain Care Board regulatory duties. And some of what you're talking about, Tom, is not a Green Mountain Care Board duty. And so I just want a level set that we have not been looking outside of our own purview. I mean, the benchmark plan is, but in terms of- The rate review is? Yes, but creating a benefit program for people over 400% of poverty is not. That's a legislative action. So I just want to be transparent that it's not going to address all of the issues that I know are concerned to you. Well, my response is I probably disagree with you. I rarely do, but I probably disagree with you here. That we need to kind of look beyond our own walls to solve problems for folks. And when you look at somebody at 401% of poverty, who's premium at 399% of poverty has been 3% to 4% and they have 401% of poverty and it's 14% or 15%, you know, that's a problem. And- To be clear, I'm not saying it's not a problem. It's just not a problem that I can fix in regulatory integration. Well, but it might be. I mean, in terms of even looking at hospital budgets and how money moves in the system, we have a big impact on that. And I don't see the money in the system moving toward Blue Cross Blue Shield's bottom line so they can turn to their rate payers and say we can lower the rates. It's just not, when you have four years of history and they've only got $3.4 million in net earnings out of billions of dollars in revenue, it's a dry well. So we have to find a problem. I mean, we have to find, we have the problem. We have to find a solution to have the healthcare system be more responsive to the needs of people that are taking hypermutes and co-pays and deductibles. I would just add that, I see Ena left, but- And she's there, she's there. Oh, she's there. Oh, she's there. She's a chanceeer. She's mine, Robin. She's mine, Robin. The legislature just received a report regarding health insurance marketplace issues and this issue of premium subsidies was addressed in there. I'm sure it will be an issue that's considered in the legislature this year, but as Robin said, like it's outside of our purview that specific issue. Okay, I have the board members. Sure. I just have a few questions. Page 27. I think on this one, it would be good to also show the offsetting income. I mean, you do show it for the million 362, but for the population health investments and admin expenses, just where that's being generated by participation fees and grants and other areas. So I think to kind of round that chart would be good to balance both pieces of it. And then on page 83, just a couple of things on this chart. Juan, just pointing out, and I know we're very concerned obviously about the risk that is generated from the system, but we don't want to forget that this is also potentially a saving side as well. And so that this quarter kind of goes both ways, right? So there's a maximum risk of the 44.1 million and there's a potential savings of up to 44.1 million. To that point, I want to bring up and just kind of ask as a question, when we talk about the admin costs of 19.3 million and putting in that ultimately the admin cost should be seen as a potential save in the system. And not that I don't want to see that, I do, but I've always had a bit of a concern on where we're going to see that, right? So really this is the place, or one of the places in the short term that we need to see that, or am I wrong with that? Well, I think that's a good thing. And I think what I remember from a long back earlier was about how do we quantify the savings? And I think financial savings are just one piece of this puzzle. There are also a lot of other, there's a lot of other value that's being created across the system. And I think we need to think about how we quantify that. That may not appear in sheer savings back through this mechanism. So I think while we will see that, that is a significant portion of these real dollars, we just want to be cognizant that there might be other ways that we should quantify change to our overall healthcare system. We don't want to ignore other benefits that we've created or other challenges that might not be quantifiable in terms of dollars. So administrative burden being one of those things. How do you quantify administrative burden to our system? And I agree with you. My point is, what are the expectations for that? Because in the black and white it could be there's 19.3 million. We expect to see those savings to the system. And also because so much of this work really could depend on what's going to happen in the future. We're kind of laying groundwork for what could be happening three, four or five years down the road, 10 years down the road. So I just want to kind of put that in there because it's always been one of the requirements that we've had that I've had a concern with not because I don't want to see that offsetting savings but I don't think we've defined where it would come from. And I just want to be clear on that because on a black and white you could say, well, we should see that savings here and that's not, I don't know what the expectations are. Okay, and then my last is on page 90. And this may be something we'll go back with the ACL on. I guess a couple of points on number two. First, the four million reserves from a 2020 budget fortunately were built in 2019. So we're not seeing this impact of an incremental four million put into the budget in 2020. However, that said, I don't think that the ACO has clearly represented why they need this money because when it was built up at the 3.9 million requirement it was to cover the hospitals that were being relieved of their risk assignment, if you will. So there were several hospitals that said we would back, the ACO would back that 3.9 million. They didn't really bring up except when we asked questions that there's been a change and that the founders, Dartmouth and UVM are now gonna back those hospitals risk, which is fine. That's good. But that then, the need for that reserve had been for those specific reasons and now to carry a four million dollar reserve without the step, without what they're gonna use it for. So I guess there's still so much uncertainty with the ACO, I'm okay to keep that in there. But we really, and I know you're putting as a requirement, are gonna wanna watch what are we spending this for because some of the things they came back with liquidity risk of different areas. I mean, this reserve was built for a different reason. The 3.9 million that we built last year was built for a different reason and we're not using that for that resource anymore. So I just wanna be really clear about that. It can be something we follow up later. It doesn't impact the 2020, other than to say they could have let that flow back through the P&L and relieved some of the participation fees from the hospitals and I know they're proving that through their system. But this was a little bit, took us a little bit off guard, I would say on how it was handled. I think that's a great point. Maybe the other thing that came to mind was we're going back to the 19 office will actually issue now, so maybe we'll have more of an understanding this spring. Okay, that's all, thanks. Can I just ask you a question? Certainly. Are you satisfied with the condition on the next page that the staff is recommending around the monitoring? Yes. Okay, I just wanted to make sure that you're concerned. Yeah, I just wanted to make sure that message was heard and understand, you know, of why we're saying that. It's not that we don't think there's potential risks in the system. This reserve was built for a different reason and it's no longer needed for that specific reason and to just say, well, we're just going to keep it. You know, there are some concerns about that. Sure. So, slide 30. So, this is more of a comment on the provider reimbursement recommendation. I liked that the monitoring of the percentage of provider payments that are paid for service was expected to be a prospective payment, but I did want to make the comments that it was never anticipated that all providers would be under a fixed prospective payment either because it's a small provider that can assume risk or it's perhaps the type of service that you're not really worried about volume increasing because that would be an appropriate utilization. So, I just wanted to say that out loud and have you guys keep that in mind as we're doing this monitoring because I think there's a tendency to assume that fixed prospective payment is the way to go for all providers and I don't think that's actually the case. So, particularly when you're talking about a system where there's a total cost of care look and accountability at that level as well as at the fixed prospective payment level. So, I just wanted to really make that comment so that you can be thinking about that as we move forward. On slide 33, it just raised the issue for me. The HCA and their recommendations had suggested doing a deadline for payer contracts and while I would love to see the payer contracts finalized before December, I don't actually think it's realistic given where we currently are with scale because I think that until we get to a more stable population, the data and the numbers are gonna require a lot of careful attention and I think that's part of what is driving some of the delays in, for example, the Medicaid rate case as well as the shift, for example, the geographic attribution. And so, I don't wanna create a deadline that's gonna result in less careful attention to the data and quite frankly, I don't know how we could enforce it against Medicaid, for example. So, while I love the idea of it, I don't think it's actually practical at this point in the model to do that. So, I just wanted to make that comment so that you would understand my thinking around that. In terms of the commercial QHP benchmark, recommendation, I like carrying over the recommendations from the 2019 budget. I guess this would really probably be slide 41. And while it's somewhat dissatisfying reviewing the budget without final information, I think particularly in the QHP area, I don't think that's gonna improve given the federal rules for exchanges around grace periods and premium payment by customers, which really means that the attribution in that population can't be finalized until the end of January. So, it is dissatisfying, but I think that this process that we set up last year where we finalize the numbers and take a deeper look into the payer contracts in the spring makes a lot of sense when we have final numbers. So, I'm glad you carried that forward. I would however like to see the underlying data that the OneCare received from the payers understanding that that would probably come with a confidentiality request from both the payers and OneCare. But I think it's important for us to see that background data for you guys to be able to analyze that and also for our regulatory integration with Ravenview. So, that would be a request. I don't know if it needs to be a budget condition, but I'll just put that out there. The next topic that I wanted to talk about a little bit is slide 59, because to Ham's earlier point about the lack of understanding of the financial stuff, I think there's a similar lack of understanding around the ACO's role in the community and the governance structure for the community collaboratives, which quite frankly I think is confusing given that we have this system that we built up around the blueprint for health. And so, I just wanted to say out loud that we don't regulate the blueprint for health. The blueprint for health has a statutory government structure that would need to be changed by the legislature for us to dictate requirements onto those community collaboratives, even I think through the ACO. Because the ACO, for example, is not in charge of the community collaboratives. That is something that's done through the blueprint. That's, I think it makes a lot of, to Tom's point, like one of the things about Vermont is that we like to do things on a more local level. And so, we want the communities to be able to make their own judgments and assessments around their own priorities, because they're a lot closer to the patients than we are sitting here in Montpelier. But what that also means is that because the blueprint has created a system where the communities are in charge and there's not a lot of top-down dictation from either the state or the ACO about what those priorities should be or must be, I think that's something that we need to respect. That does mean it's harder to see the alignment, necessarily, at the very highest level with the APM goals. So that's something that I think we should, particularly if we aren't seeing results that we would like to see, that's a conversation that should happen. I do think it's bigger than us. I think as this shows, it's a conversation that has to happen with the blueprint and all the payers. And I'd love to see some of the communities involved also talk about that, because I think one of the complaints at the community level is administrative burden. And when we talk about adding requirements that basically flow down to those communities, we should understand that that's what we're doing and understand the burden on those