everyone to the Green Mountain Care Board. The first item on the agenda is the Executive Director's Report, Susan Barrett. Thank you, Mr. Chair. I have a couple of announcements. First, that we are reimagining our general advisory committee meeting, the Green Mountain Committee, not meeting, just the committee. We have an application and that will be available on our website. And we are accepting applications until December 7th, so stay tuned on that. We are, I also have an update on the vital budget. And I wanted to let the board and the public know that the board, you did review and approve Vital's 2019 budget in May of this year. And that budget included estimated amounts for Vital's January through June 2019 contract with Diva. At that point, it wasn't negotiated yet when you were looking at the budget. So we asked that Vital provide additional information in late 2018 once it had its contract finalized with Diva. They have in fact did that, do that. I can't talk today, I don't know why. They have in fact done that, it's a proper tense. And on November 14th, Vital provided a memo. They updated their financials and with updated financials and a copy of its final 2019 contract with Diva. And the staff reviewed this, the board saw it and the materials satisfied requirements of the budget order and confirmed that Vital's FY 2019 budget has not changed. Materials of the contract will be available on the Diva website shortly. They're just finalizing that information. So if anyone has any questions, they can contact Sarah Kinsler on that. The last thing I wanted to mention was our schedule for the rest of the month. We do not have a meeting on Wednesday. Happy Thanksgiving to everybody. Next week, we have a meeting on the 28th of November and it's an all day meeting. It starts at 10 a.m. And then we'll break for lunch and come back in the afternoon.  Any questions? Happy Thanksgiving, everyone. Thank you, Susan. Happy Thanksgiving. So at this time, Sarah, actually, do we have a motion on the minutes of Wednesday, November 14th? So moved. Second. It's been moved and seconded to approve the minutes of Wednesday, November 14th. Without any additions, deletions or corrections. Is there any discussion? Seeing none, all those in favor signify by saying aye. Aye. Any opposed? Okay, Sarah Kinsler. Thanks, Kevin. So for the record, this is Sarah Kinsler, the board's director of strategy and operations. As a reminder, I was tasked in 2017 with staffing the board's work related to vital health information technology and health information exchange. So I'm just gonna give folks mostly for the audience's sake a quick reminder of the process that we've used on this on November 1st. Diva and Vital submitted a health information exchange plan and connectivity criteria for the board's consideration. We had a special public comment period from November 2nd to 15th and received one written public comment. On November 7th, Diva and Vital presented the HIE plan and connectivity criteria to the board and there was some discussion. In addition, we received three public comments that day. And then today, I'll make a final staff recommendation to the board and there's a potential vote on the schedule. So I'm gonna run us very quickly through the suggested criteria that we provided on the 7th to support the board's review of the plan and the connectivity criteria, run through the staff assessment of the plan and connectivity criteria is meeting or not meeting those criteria and then make a staff recommendation after we talk a little bit about the public comment we received. So the first criteria is whether the HIE plan is consistent with the statute related to the HIE plan. There are a number of statutory requirements for the plan in section 93.51, including supporting effective, efficient statewide use of electronic health information for a variety of purposes, educating providers in the public, supporting interoperability, proposing strategic investments in technology and infrastructure, recommending some funding mechanisms and incorporating existing initiatives whenever possible, including the blueprint for health and MMIS systems. In addition, the plan's required to address issues related to governance and security. As submitted on November 1st, the plan does meet each of these criteria with the exception of proposing specific technology investments. In their presentation, DIPA provided some pretty good, I think, reasoning for this, specifically that it doesn't make sense to propose specific technology investments in advance of some major governance changes. So I think we can expect to see that in future years. The plan also lays a solid foundation for some thoughtful technical investment recommendations in the future by doing a very thorough job describing the technical aspects of HIE. The second principle for review is, is the plan consistent with the principles for healthcare reform? And I believe that it is. There are a couple of principles for which it's particularly relevant. Principle number three is really focused on system transparency, efficiency and accountability. And I think that the plan speaks to each of these concerns in a variety of ways. Principles four and eight focus on the central role of primary care and the importance of the relationship between individuals and their healthcare providers. I think, again, the plan's support for an accurate longitudinal health record for every person would very much support these goals. Principle number nine is focused on continuous quality improvement. As Divas spoke to on the seventh, there are a number of applications for a high quality HIE system in supporting quality improvement, continuous improvement throughout the health system. And then principle 10 focuses on eliminating excess expenditures. And again, I think there's a lot of room to decrease duplication of effort and testing through a longitudinal health record. And then finally, principle 13 is focused on system-wide partnerships and collaboration across the public and private sectors. And I think that that is a particular strength of this HIE plan. The third criteria is related to the HIE plan's consistency with other relevant legislation. In particular, we looked at Act 187 of 2018 this year since that was recent and it included some pretty strange criteria for DIVA to advance the plan. DIVA did meet all of the requirements in the Act 187 work plan. And then finally, the fourth principle asks you to look beyond Vermont at best practices and exemplars from around the country as well as to ensure that the HIE plan has been vetted by Vermonters. In terms of national best practices, the HIE plan builds on national standards and models for HIE governance as well as for technology and IT services. DIVA and the HIE Steering Committee consulted with the Office of the National Coordinator for HIE, including experts from Colorado, Oklahoma and Michigan whose HIEs are national experts in various areas, especially in governance. And then again, the HIE Steering Committee and DIVA sought quite a bit of feedback from Vermonters in various stakeholder groups, including during an HIE road show in September. So switching to the connectivity criteria which are included as part of the HIE plan. There were two criteria that staff developed for this. First, alignment with the HIE plan and state goals. I believe that the connectivity criteria are well aligned with the HIE plan and state goals. They will support the HIE plan's goals and structure and will support increased availability of high quality usable data in the future. Second, are the proposed connectivity criteria clear and operationalizable? I believe that they are. The proposed criteria were developed to expand providers' ability to submit and receive structured data from the VHI in part by providing specific standards and requirements to support Vermont providers in their contract negotiations with the EHR vendors so that they're actually implementable on the ground, much more so than previous connectivity criteria. So those are the principles for review. Here's a quick summary of public comment. As I said earlier, we received three verbal comments on the November 7th meeting, two from consumer advocates who spoke to the complexity of the HIE system, the expense of HIE and EHR investments and the challenges that EHRs present for healthcare providers, as well as the value of EHRs and kind of the longitudinal health record aspect from a consumer perspective. Secondly, a representative of the Bi-State Primary Care Association commented verbally in support of the HIE strategic plan. And then lastly, we've received one written public comment during the special public comment period from the Office of the Healthcare Advocate, expressing concerns about consumer engagement in the proposed HIE steering committee. So in light of the principles that I presented earlier and the public comment, my recommendation is to approve the 2018 and 2019 HIE information HIE strategic plan, including the connectivity criteria as submitted with one suggested revision to add GMCB as a stakeholder in each connectivity tier and the connectivity criteria and to mention the requirement to include connectivity tier information in HIT-related certificate of need applications. Okay, questions for Sarah? Okay, is there any public comment? Eric. Hi, my name is Eric Lopez. I'm the Office of the Healthcare Advocate. It's been, I would just ask the current language for the permanent governing body of the HIE is for a consumer advocate, it's someone engaged with the healthcare system. I think that language is too broad to guarantee that it's a consumer. And I think it makes the relatively simple change to have it trapped the language for a consumer member of the board that's in a statute for vital board membership. And I think that's a simple change that I would practically ask the GMCB to consider. Are there other comments from the public? Seeing none, would any member of the board like to make a motion? Yes, I would. I'd like to move that the board approve the HIE plan as submitted and recommended by staff, including the connectivity criteria as embedded in the plan. In support of that, I think I would like to applaud the folks at Dieve and the steering committee for doing a good job. This is a long way down the road from where we were when the health tech report was published and the problems that we were having in this area of healthcare. And the kind of sequential nature of the plan, the building blocks from the bottom up from issues such as identity management and consent management as foundational to the top tier of analytic services and consumer tools, I think has been well thought out and that the board should support it. I would comment that given the complexity of the plan that it'd be important that the steering committee be a stable organization at least for the first two or three years. And so as you seek to appoint folks to that, obviously there are no guarantees, changes of administrations, things of that sort. But if you can seek to have involved in the steering committee, folks that understand the plan and have participated in its creation, I think that's important rather than having a lot of turnover in this regard. I also think that consent strategy is really important or wherever that steering committee takes that strategy and I understand that there are a number of options but timing is important here and that shouldn't, given that it's a foundational consideration, it shouldn't be one that kind of stalls the progress going forward. And finally, in response to Eric's comment, I think there is a lot of opportunity and this isn't part of the motion, just a suggestion. I think there is a lot of opportunity to strengthen the consumer participation on the steering committee and that might be especially important when it comes to the consent issue to have a consumer on the steering committee that is not burdened by being a state administrator or a healthcare provider or an insurer. And so I would urge you to spend some time with the healthcare advocate to see if there's a path forward that everybody finds reasonable. So with that, that's my motion just to repeat it because I wandered a little bit there is to move to approve as submitted and recommended by staff the AGI plan as including the connectivity criteria as embedded in the plan. I think I might have a friendly amendment or a clarifying question, which I will perhaps state now, which is in, I think that by your motion included as recommended by staff which would include modifying the document of the connectivity criteria to be clear that there's also a statutory requirement that we look to the HIE plan and the connectivity criteria in CON. So if that's not embedded in your motion, my friendly amendment would be to include that change. It's an acceptable amendment to me. I'd have to go back and look at the CON legislation to ascertain whether it's necessary or not. But if it's not necessary, it would be too clear of what already exists. So I view it as a friendly amendment. All right, I will second. So it's been moved and seconded before the board takes up discussion on the motion. I would like to ask Deputy Commissioner Costa if Diva would like to respond to the healthcare advocates letter. Sure, good afternoon, Michael Costa, Deputy Minister of Department of Mental Health Access. I very much appreciate the written comments of a remotely late in the office of the healthcare advocate. I would just tell you what we were trying to do with the language around consumer representation. We were trying to encompass the fact that while some people are consumers of healthcare services, there are also caregivers and other folks that are not direct consumers, but have a stake in this. We very much appreciate the suggestion and if that's the board's will, we'd be happy to work with that. And we'd be grateful to have a consumer on board next year. As we've discussed in part of both legislative committees and this board, the HIE program needed to be brought on track. We had a group of people that we knew could help us bring it back on track now that there's a specific plan, look forward to broadening that governance and having a larger group interface with the HIE work and making sure we have consensus work and investments in the future. Happy to have a dialogue with the office of the healthcare advocate on the amount of consumer representation over time. I think that's a good subject to revisit as Diva brings a plan back to this board next year. We'd be happy to have that conversation. Before you sit down, I think there were really three suggestions that weren't part of the main motion but that were suggested by the maker of the motion and the three items, besides the consumer representation, was a long-term commitment that people appointed. We cannot speak for those people but we want to encourage, as we said before, Mr. Chairman, that for anyone who's going to sit on this committee, that one, they're prepared to do real work and two, they're prepared to do that real work over time. Okay, this program more than most would benefit from stability and commitment over time. And do you have any comments regarding the amendment by member Lange on the CON? Okay, great. Thank you. Thank you. Is there further discussion? Can I just clarify one thing? There was a recommendation about long-term commitment and I don't know if that's going to ever be enforceable as was discussed here. He said it was just a suggestion. Right, I'm not sure that he was making that. I don't know if we'll make that into the order as far as we order that people have a long-term commitment but saying that that was an amendment to this, I don't know if that's exactly the meaning to the motion. It wasn't intended as part of the motion. It was just a discussion. The way I understood what he said, he was just suggesting these things to Diva for their consideration. My only comment would be, I tend to agree that the current language around the consumer representative is a little vague, although I know Emily in her discussion did say that, as Michael also pointed out that that came out of a desire of trying to have broader language to be more inclusive, so I don't feel like I, I feel like I understand the intent and don't necessarily need to order the language change but I would just say out loud that I do think we'd be, when Diva comes back, I at least would be looking to see that the spirit of that was maintained. I haven't heard anybody disagree that it's not a good idea. And my understanding then also is that it is not an actual change. It was another recommendation that, but it wasn't a change to what was being supported and recommended by the staff. Yeah, the only thing that's changed from the recommendation from the staff is the CLN report. So is there other discussion? Seeing none, all those in favor signify by saying aye. Aye. Any opposed? So let the record show it was unanimous vote. Thank you, Sarah. You did a great job preparing us for this. As always, your work was stellar. Thank you very much. And thanks to Diva and Vital for being really strong partners in putting this together. Okay, so at this time we will invite Deputy Commissioner Acosta and Director Alicia Cooper down front. Again, Mr. Chairman, Michael Acosta, Deputy Commissioner, Department of Vermont Health Access. Alicia Cooper, Director of Payment Reform, Department of Vermont Health Access. Very pleased to be in front of the board today to talk about the Vermont Medicaid Next Generation Program, which of course is Medicaid's program that connects with the Vermont All-Payer ACO Model Agreement with CMS. We're here to talk about 2017 program performance, an update on 2018, and an update on our planning for program year 2019. I would say that hopefully we have an interesting story to tell and we welcome your questions. I'm gonna hand it over to Alicia in a few moments. Alicia is our Director of Payment Reform and her team runs the ACO program on a day-to-day basis. We're joined today by Amy Kunroth, who is the ACO program director and has done an enormous amount of work to try to make this program successful. And what all I would say before handing this over to Alicia is that I think one of the most difficult parts of this program is that it's going to just take time to understand its impact in performance. As the board can well appreciate, we're in month 11 of performance year one of our six-year agreement with CMS. Medicaid had the opportunity to get out of the gate a little more quickly and so we're on our second year of the program. But we want to urge people to exercise real caution with how they interpret these results. And because it is just far too early to take the experience we have and draw any medium or long-term conclusions. With that said, we're really grateful for the dialogue we're going to have with you today and with other policy makers in Vermont over time. Alicia. Thank you, Michael. Just as a reminder, we signed our original contract with OneCare Vermont for our first performance year, which was the 2017 performance year. That contract gave Diva and OneCare the option of four additional one-year extensions. Diva and OneCare triggered the first of those optional extensions for the 2018 performance year that we're currently in and has also decided to exercise the second one-year extension option for a 2019 performance period. Rates are renegotiated on an annual basis and financial reconciliation may occur more frequently than annually, although for the first performance year we did the annual reconciliation after the completion of the first performance year. We'll start with an overview of 2017 program year performance, and I'll reference in some instances the 2017 results report, which was submitted to the legislature and to the Green Mountain Care Board and others on September 20th. So if you have a copy of that to reference, that may be helpful and hopefully it'll be a helpful resource as you look into it over time as well. We tried to summarize the results of the 2017 performance year in the report in the form of an executive summary that highlighted results in five key areas. The first area was that Diva and OneCare launched the program successfully. There was quite a bit of work that went into preparing for the first contract year, and one of the key activities was the conducting of a readiness review prior to the start of the 2017 program year. We did this readiness review with OneCare in the fall of 2016, and OneCare had completed the majority of the review requirements prior to January 1st of 2017, and all outstanding items which were not deemed necessary for program launch were completed within the first quarter of 2017. Diva also had to do quite a bit of work with our fiscal intermediary partner DXC Technology to ensure that Medicaid payments could be changed to allow for Diva to make fixed prospective payments to the ACO rather than just fee-for-service payments to providers as we have done previously. In the first year, we also worked closely with OneCare and with DXC to develop a process for ongoing data exchange. This process has been implemented and we're regularly evaluating and monitoring whether the process is working and seeing if we can identify opportunities for improvement. We do have several targeted areas for improvement of those processes highlighted for the 2019 calendar year. Another thing that Diva and OneCare worked together on was the development of an operational timeline that we could monitor so that we would be sure that both parties were adhering to deadlines that were included in the agreement. We report on the adherence to this operational timeline in our quarterly reports to the legislature. OneCare and Diva also in the first year developed a forum for convening the operational teams of Diva and OneCare on a regular basis, typically weekly, and for convening broader groups of Diva and OneCare subject matter experts on either a monthly or quarterly basis to allow for dialogue, continual process improvement, and the identification of any challenges and solutions as needed. And finally, we had worked pretty closely with OneCare throughout monitor program performance. That includes financial performance. And I'd say that the first year was a real learning year for both Diva and OneCare in understanding how best to operationalize our financial reporting and how to do comparisons and validation on a regular basis. I think this is an area where we can continue to improve, but we did do a lot of foundational learning in this first year. The second result that we highlighted in the report was that the program is growing. This table summarizes 2017, 2018, and what we were anticipating for a 2019 performance year with respect to hospital service areas that have voluntarily elected to participate in OneCare's Vermont Medicaid Next Generation program, provider entities that are participating, unique Medicaid providers that are participating, and the number of Medicaid members that are attributed to the model. As you can see, in 2017, we started with four communities participating and approximately 29,000 Medicaid members attributed. This grew in 2018 to 10 communities and about 42,000 attributed members. And in the 2019 performance year, we are anticipating 13 communities and approximately 79,000 Medicaid members being attributed. The third result that we highlighted in the report was that the ACO program spent less than expected on healthcare in 2017. For our contract with OneCare, Deva and OneCare agreed on the price of healthcare at the beginning of the performance period for the attributed lives and for the services that were included as part of the total cost of care. Based on the ACO's financial performance in 2017, the ACO spent approximately $2.4 million less than this expected price that was agreed upon upfront. And because this financial performance was within the plus or minus 3% risk corridor that's in our contract, OneCare Vermont and its member providers are entitled to retain those dollars that were less than 100% of the total cost of care. The fourth result that we discussed in the report was that the ACO met the majority of its quality targets. The ACO's overall quality score for the 2017 performance year was 85% based on their performance on 10 quality measures. OneCare's performance exceeded the national 75th percentile on measures relating to diabetes control and engagement with alcohol and drug dependence treatment. And we'll continue to monitor performance on quality over time to make sure that we can understand the impact of changing provider payments on quality for Vermonters. This slide is a summary table that shows some of that quality performance. This information is also available in the 2017 report, but I think some of the color coding is helpful to see where there is green and yellow you see performance that is above the national 50th percentile. You'll also notice that we have some measures where we don't currently have national performance benchmarks available for comparison, but we expect more measures will have those benchmarks in future performance years. The primary limitation in 2017 was that we had some brand new measures nationally being used. And the final result that we highlighted in our report was that Diva is seeing more use of primary care among ACO attributed members compared to a comparison cohort of Medicaid members who are considered eligible for ACO attribution but who are not attributed to the ACO in 2017. I'd say that these are based on preliminary analyses of utilization and we haven't done any significance testing for these results, but we are generally seeing across all age groups and across several historical time periods and the 2017 performance year more primary care utilization among those attributed members. And this is something that will certainly be interested in monitoring over time as is utilization in other categories and there is some additional information about utilization for the attributed cohort and the non-attributed comparison cohort that's available in our quarterly legislative reports. Pause there. Do you have anything that you would like to add? Nothing other than through the first performance year the state finds the results encouraging, but it's too early to draw any definitive conclusions. I think Diva is really committed, the state is really committed to steady incremental progress in its ACO program and we're trying to learn everything we can from 2017 to improve the program for Vermont and Vermonters in 2018, 19 and in future years. So can I do a follow up question on that since you're talking about it's too early to really make any conclusions. Before we go on to 2018, can you go back to slide seven? So there was $2.4 million of savings over what the agreed upon amount was, but how was that amount figured and how are you extrapolating the information from 2016 to come up with the numbers for 2017? So I'll start and Alicia you feel free to jump in. So what happens is the ACO brings us their provider list and we run an attribution methodology which is just a fancy way of saying, okay, who are my people? Who are our members that are gonna be in the program? Then our actuaries take a look at the claims history of those Medicaid members and they develop an actuarial range. One care and their actuaries scrutinize that same data and we negotiate what we believe is the set price for the year for those healthcare services. And each month we're tracking actual expenditures, both in a fixed perspective payment and fee for service claims against what we anticipated seeing. And so at the end of the year, you compare what the expected cost of care was, the price versus the actual cost of care both in terms of fixed payments made to the ACO and fee for service payments made to providers inside and outside One Care's network. Well, we really have been referring to this as the price. We've tried to get out of, we've tried to differentiate this program from a shared savings program. The thing, one of the things the state really wants financially is financial predictability and sustainability. And so we get the benefit of that fixed price upfront and then what happens afterwards is really between One Care and its members. One of the interesting operational pieces is that in a fully capitated world, if we just sent monthly payments to the ACO, they would have the money upfront, right? But since there's still this fee for service component of it, we have to keep tracking it over time to see what actually happened. I think so far, you know, and then what happens with ACO and the savings of it, it's a matter of between the ACO and its network, how they distribute that and I'm sure that's part of your budget deliberations with the ACO. Does that answer your question? Kind of. What percentage of the Medicaid lives were directly attributable to One Care and the ACO? So in 2017, we start at 29,000 lives and remember people drop off every month if they no longer remain eligible for Medicaid in very rough terms, it's about, it was about 20% of all full Medicaid beneficiaries inside the program. So we have around 130, 135,000 full Medicaid beneficiaries, about 160, 170,000 beneficiaries once you factor in limited benefit packages, but it's about 20 plus percent of full Medicaid beneficiaries who could be eligible for attribution and that number is growing over time. So the other 80% in 2017, how did they come into your budget? Were there savings overall in Medicaid or did they come in on budget or over budget or what? I would say so let's take a little step back. So when we're building, when the agency of human services and the administration are building a Medicaid budget by law, there's something called the consensus forecasting process where the administration and the legislative joint fiscal office come together to determine the best estimate of how much Medicaid healthcare spending is going to cost and then the joint fiscal committee confirms those, the emergency board rather, confirms those estimates. For us, what we are doing over time is to try to make sure that our forecasting and operations reflect this program. And so we take what we think is the full estimate of Medicaid expenditures and then make sure that this price fits firmly within that estimate. So in other words, we try to make sure in our negotiations with the accountable care organization that we're paying the same or less for ACO beneficiaries than we would in a fee for service environment. I'm sorry, I feel like a little case of mumblemouth. I'm trying to make this understandable but these are really good questions that get into the technical weeds of it. So you saw savings on the attributed lives to one care. What did you see on the non-attributed lives? I would say for calendar 17, which would say the reason why I'm pausing to think about this for a moment is because the ACO runs on a calendar year where state government runs on a fiscal year. And so you have two different fiscal years intermixed in the ACO program year. I think generally Medicaid has had sufficient resources at the end of the fiscal year for the past two years but it's hard to compare those two things together because we had not run those comparisons and there's more in the bucket than just these services. I would say generally as a general matter with a lot of complexity off to the side both the ACO program and those outside the ACO program are spending a little bit less than we anticipated but I think we're getting better over time at running those comparisons because it's becoming a bigger part of our business as a public health plan. So I know it's too early to tell but if you had your preference you would want to expand the number of lives in the ACO model, correct? Yes, and we think that the ACO program offers the state a more predictable experience financially than those members who are purely in fee for service. It's a more straightforward way to assess what it costs and what the quality results are. And so I think the state will continue to move people into that program. Well, hold on, the state will want more people and providers in that program until we see different results. Because remember, one of our five findings here is that the program is growing but that's not the state. The state is merely creating the opportunity for healthcare providers to work together in a different way but the ACO is a coalition of the willing and providers have to choose this program themselves but we will continue to create the opportunity for healthcare providers to come together in a different way as long as the results continue to be promising in the way that they are now. Yeah, I just wanted to clarify on when you talk about the 2.4 million savings it looked like from the reports that that really was the savings from the fee for service world and that there was a potential shadow savings of about eight million dollars in the rest and just wanted to know how you think about that. I know that that's given to them as a fixed perspective payment and one question would be because it's given as a fixed perspective payment how accurate are the shadow tracking? Because they're getting the fixed perspective payment and you just wonder whether they're putting everything through there because we seem to be showing a bit of favorability in that area. That's an excellent question and just to make sure everybody's on the same page you're absolutely right. The program pays in two different ways a fixed perspective payment which by and large gone to hospitals and then fee for service payments. Now the state of Vermont and the federal government are always going to know want to know what happened when you received that fixed perspective payment and so healthcare providers are required to submit shadow claims. It's just a claim where we don't pay it to make sure we understand what healthcare services were provided to Medicaid members. Now we keep track of the value of those shadow claims and as you said there is a large gap between the fixed perspective payment and the value of the shadow claims. The tricky part is we are offering a payment reform where we give healthcare providers a predictable financial base so they can try to work in a different way and so it's not an apples to apples comparison to say this is what would have happened in fee for service versus here's what happened in shadow claims. For example, let's take back surgery. We don't know whether the fixed perspective payment made a healthcare provider more willing to continue to use therapy and other non-surgical interventions rather than surgery. If you continued with those non-surgical interventions you likely have a smaller shadow amount than the fixed perspective payment amount and so you have to be really careful not to add those up as if those were savings that could have been captured because you don't know what the healthcare utilization would have been if you're still in fee for service. Now the fail safe to make sure you're still getting the best deal for taxpayers is that when the state negotiates in the future with the ACO about what the right price is for healthcare the actuaries look at that past claims experience and say, okay, based on that for example that gap there what's the right price in the future, right? Should you really stay at the same level you are or some higher level when there's this gap between what you paid in fixed perspective payments and shadow claims or does the price need to be adjusted in some sort of way and that's where it'll catch up and you can take some, you know have some actionable advice from those shadow claims. When that's done, how does that then reflect as being savings? Cause it is savings to the system overall if you start to take a base in the fixed perspective payment world and there's favorability and then over time use that in the future. I'm just trying to say like, how do we capture that? You know, in the numbers because that's a big graph. I will just do the board the service of sharing with you how we talk about it internally at Diva and that's that we're trying to get away from the word savings and we're trying to have a conversation about what is necessary versus unnecessary utilization of healthcare services because our thinking is that over time as the ACO presumably gets closer to having a fully fixed perspective payment and less fee for services, fee for service payments we're gonna be thinking very hard about what we believe the right utilization of healthcare services is, right? And so for us, we're gonna want some more data about whatever the gap is positive or negative between fixed perspective payment and shadow claims so we can both figure out what we think the utilization trends will be once we have a full cohort of people and then also whether that should impact the price at all. Right, and so I'm sorry to make that overly complicated but it's a really compelling question and one that as we negotiate the third year of this program is starting to really come out. You know, how do we think of shadow claims in a ACO based world? And if anybody has a better term for them than shadow claims, we are all ears. But the other way we think of them is the would have paid amount, right? What would have we paid? But we think that's an imperfect term because again, we don't know what would have happened if you didn't have the new incentive of a fixed perspective payment as opposed to fee for service. No, that's good. I mean, in your example too, you could actually have people that switch, say the back surgery example and you didn't do that but there was a lot more physical therapy that might not be within the system than that would be a reason why fee for service went up and there could be some shifting between the two as well. And that's, to me, one of the things I appreciate about this question is, I think you can take a look at the five findings that Diva's presenting on the ACO program today and say geez, you know, that's pretty modest. We successfully launched the program but we happen to believe that it's a pretty important milestone to be able to pay in a different way to offer this fixed perspective payment because it's changing the incentives in healthcare to see whether providers will come together and work differently. We don't know the answer to that but the first year is encouraging and it gives us confidence that we should at least continue through 2019 and make plans as if the program is going to continue after 2019. Thanks. 2018. Oh, Tom. So I'm a little interested in this consensus process with the administration and the Joint Fiscal Committee and just wondering how granular that estimating process is. When there's a discussion on Medicaid, does that include nursing homes or is it subdivided to a point where we looked at it, we could see the connectivity between that process, the governor's recommend and what the ACO budget expectations are. Again, I know it's over two fiscal years but I'm just wondering how granular that consensus process is. So what I'll do to try to answer your question is tell you what we do today, what we're trying to do in an ACO based world and then the gap between the two and describe a little bit what progress is gonna need to be made to get to our preferred future in this. So in the consensus forecasting process, we're not taking all of Medicaid, we're taking basically healthcare spending that's hospitals, doctors, transportation, choices for care, and we're coming up with our best estimate and it gets more granular the closer you look at it. It starts with, okay, what's the big number which for us ends up being about a billion dollars, then underneath that we estimate by category of service which is just a fancy way of saying, okay, we think we spend a little over a hundred million for hospital inpatient services, we think we spend a few million on durable medical equipment, et cetera. And then underneath that we're looking at it at the member level. So at the bottom of it, we see a per member per month estimate depending on what Medicaid eligibility group you're in because there are lots of different doors into Medicaid and the spending for each group can be really, really different. New adults who are only in Medicaid because of their income spend about this much. If you're an age-blind or disabled Vermonner, we're probably gonna spend a little more on you. And so that's the level of spending we're trying to, the level of precision we're trying to achieve in the consensus forecasting process. Now the ACO program did not change that on day one. It was a small enough cohort where it's not going to potentially move the whole thing on day one. And then also we have the failsafe of we're using an actuarial range that fits within our budget estimates. So we have some confidence that it's going to be around what we expected to spend in the status quo before the ACO program. And so only now are we really trying to tease it apart at the fine level you described, which is okay, do we have a situation where that per member per month estimate could be different for people inside the ACO and outside the ACO? And what would that mean for our budgeting? I think that we still have some work at Diva and the AHS central office and the joint fiscal office to make sure we're all on the same page and understanding the data so we can do that because the consensus forecasting process is supposed to be a nonpartisan process that's for the benefit of all of our monitors. But I think we're finally now as we enter almost a conclude year two of the program and enter year three of the program at the point where we can have that discussion. Now I would say the big obstacles to having that discussion are one, making sure everybody's on the same page. Just the cultural thing of it, hey, it's a new program. Do you understand it well enough to understand the relationship between cause and effect in a reasonable way? Two, coming out of the ACA, we're still seeing a little bit of movement in the cost between the Medicaid eligibility groups and just the way we enroll people for some reason we're seeing more people in some Medicaid eligibility groups and fewer people than others and that really matters on those estimates so where this program is giving us a reason to really take a hard look at our eligibility rules to make sure people end up in the right category because it matters for this program and it matters for our Medicaid waiver with the federal government. And I'd say the third thing is just having some sort of reasonable hypothesis about how healthcare spending is going to grow or not grow in an ACO based world, right? And we just don't have a lot of experience with that since this is only year two of the program and we won't have the results for year two until the summer of 2019. So I think those three things are headwinds for doing what you described but we're trying to go in exactly the direction of your question which is can we understand this at a fine enough level where we understand the impact per member by group inside and outside the program so that can inform state budgeting and presumably can inform other regulatory processes that involve healthcare spending. I think that's part of the professionalization of the program and the growth of the program but we're on the front end of that rather than the back end of that. Well, thank you for that. I just worry a little bit in the back of my mind that if the ACO and the population health strategies are successful and we are beginning to see quote unquote savings or if there's a better word that some in the budget making process might be looking over the fence and saying we can back those savings out and move them somewhere else in the agency or state government. And so I am interested in all these connections here so that we can have a good kind of scorecard or visibility that the achievements of the ACO stay with the ACO. We've tried to be, that's an excellent point and we in operating this program at DEVA DEVA has tried to be very respectful of the fact that healthcare providers, hospitals and doctors need financial predictability to change the way they care for people and change the way they run their businesses. And so we've tried to be really careful with the forecasting and to not make any sudden changes to be respectful of the fact that that transition is difficult and it's going to take time and the more predictable partner we can be the higher chance of success that program will have. I think as a payer, DEVA is in a funny spot. We have both our role in providing care for our members at the best price for Vermonters but also having a real stake like the board in the success of the healthcare system overall. And so DEVA has tried to be very incremental in pushing the ACO and trying to make sure it's having slow and steady progress rather than pushing them too fast to make sure you're not going to push so hard that the whole project tips over. It's caused us to ask a lot of questions about for example, what's the right target for growth? What's the right quality withhold? And just to really think hard about what the right rate of progress is. And we've chosen slow and steady as opposed to big movements. Thinking that will serve us best at least over the short and medium term. Okay, Jess. Just a quick question on slide 10, which is the slide that depicts the primary care visits. Yeah, just a quick question. I would have expected that the attributed lives once they're enrolled in the ACO would see higher primary care visits relative to the non-attributed lives simply because we're moving towards more primary prevention and things like that. But this was starting prior in 2015. So I'm just sort of curious if you could just talk a little bit about what you're noticing about the attributed population versus the non-attributed population prior to enrollment that might explain it. I think that's a great question. And I think I probably won't have a great answer for you today. But utilization is certainly an area where we're trying to spend more focus as the program grows. I think one of the challenges that we're going to be looking at as we have more years of experience is that that attributed cohort is going to continue to grow each year and the unattributed cohort will necessarily get a little bit smaller because they're parts of a whole. And so we'll have to be understanding patterns for sub-cohorts within an attributed cohort to understand what it means if you've been attributed to the ACO for several years versus if you've been attributed to the ACO for only one year. I think one thing to comment on is that in both 2015 and 2016 we also had the Medicaid Shared Savings Program underway. And so it's likely, although I would have to look more specifically at the individuals who are included, that the folks that are in the attributed cohort historically had some relationship with providers that were part of ACO arrangements as well. So does that make sense? Could it be explained by the fact that the provider community that values primary prevention and sees the need for this population health management would be the first movers to get in on the ACO would have been the first ones to get into shared savings. To some degree they're already ahead of the curve in doing the things that we want them to do back in 2015. Could that explain just selection bias into the program? People who value this kind of work? I think that's certainly possible and I think your point is a good one. It's not a randomized experiment by having our attributed cohort and our comparison cohort. It's probably the best comparison we've thought of right now but I think something about the providers that are choosing to participate in this kind of alternative payment arrangement at its outset are probably those who have been engaging in innovative things for a while. And just to bring the point home, in discussing whether to even make this a finding in the program, your point is really well taken. We have one year of what but we don't know why. And what we don't wanna end up being is in front of policy makers next year what I'm saying but you told me there's more this or you told me there's more that. We just don't know yet and we're trying to really resist making big claims about the program until we know more about it. It certainly is consistent with our hypothesis about how this would work. That a bunch of provider network that really was committed to primary care came together that you'd see more primary care utilization and your point is really well taken that the ACO program did not appear out of a vacuum in 2017. It's part of a broader Vermont healthcare reform efforts has been focused on primary care for a very long time dating back to the blueprint in that there was an ACO program that was fairly well developed before the next generation all payer ACO program. And so how much of that is part of the culture and how much of that is part of this specific program I think is still to be determined with future results. We're good to move on to 2018. Great. Thank you very much. We'll step forward into our current performance period. The 2018 performance year is currently underway. One of the things that we like to note and I think this is consistent with some of what Michael has mentioned already is that because of the claims lag it is not possible for us to fully evaluate 2018 financial or quality performance at this time. It'll be several months into 2019 before we'll really have confidence in our calculations of either of those pieces. We do submit the quarterly reports. We have the June 15th and September 15th reports already available. And so some of what we'll be talking about in the next slide will look familiar if you've read the September 15th submission. One of the things that we've been keeping an eye on over the course of the performance period in 2018, in addition to something that we were looking at throughout 2017 was attribution in the model. As a reminder, attribution of Medicaid members for the Vermont Medicaid Next Generation Program occurs prospectively at the beginning of a performance year. No additional Medicaid members can join the attributed cohort during the course of a performance year, but individuals may fall out of the attribution for a number of reasons, typically related to loss of Medicaid eligibility or loss of comprehensive Medicaid benefits. Something that we weren't really certain what it would look like was the attrition over the course of a calendar year. So knowing that we're starting a performance year with a fixed cohort and knowing that some of them will necessarily drop out over the course of that year, how much will we be left with at the end of the year and is there anything that we can learn from a first year with a limited number of communities participating that would apply to a second year or potential future years? There's a subtle operational thing that I think is important to the board here in this slide. We were happy to be participants in the board dialogue on provider administrative burden. We buy the idea that if you really wanna simplify provider administrative burden, things need to start working in the same way across entire panels. And one of the struggles with the ACO program is that the good news is that providers know who's in the program at January 1st, but people drop off over time and Medicaid doesn't have open enrollment. We enroll eligible Vermonters from January 2nd through the end of the year. And so that creates for practices, folks that come onto their practice and are not part of the program. And so we've been thinking about different ways that we might make that a little less burdensome for providers. One way is to explore alternative attribution methodologies, which we're still thinking about. I don't think we're ready to make any announcement yet, but we're thinking about whether attribution could be modified and that's a conversation we'd have to have with the board and the board staff to try to stem that gap. And the other thing we've done is we've repositioned VCCI, the Not Chronic Care Initiative, and we've retooled VCCI to work in the following way. They're becoming the front door of the Medicaid program. If you enroll between January 2nd and the end of the year, VCCI will do the same risk stratification that the ACO does. They'll engage patients in a similar way that the ACO ought to be doing. And then they're gonna start to care manage those Medicaid members in a way that's similar to the ACO, building an on-ramp. So when those folks are eligible for ACO attribution in the next year, there'll be a very similar experience for them. And those are just things we're trying to do to make the care of people and the work associated with people, the same both inside and outside the ACO. So providers, it's a similar experience. So you don't have these, you start to break down those walls between the different Medicaid cohorts in service of getting providers a more simple and uniform experience with Medicaid members. That information transfer between VCCI and ACO is really on-boarding. They'll be smooth and seamless for somebody who comes on board. The goal is smooth and seamless. We were just about to start the second year of those transfers. I think we're getting better at that, but it's always a work in progress. I think that VCCI traditionally has dealt with some very complex cases. And I think we're gonna continue to just keep working on that and try to make that as good as possible. I would say that the VCCI story is that change is hard. And so there are folks that are accustomed to one thing as they move over to the ACO, it's different. But we have a very good dialogue between the VCCI team at Diva and the folks at OneCare and have tried to find the right degree. What's the right point for a handoff and when should VCCI retain people? And we work through all that on a member by member basis to make sure we're getting it right, but it still probably needs to improve over time. What's the role of a care navigator in that system and the software system in that transfer? I would want to defer to ACO and folks in VCCI about how they use that software tool. I can tell you that the ACO and Diva are having dialogue about sharing electronic tools and so that the use of tools can be seamless. And that's a discussion between program and legal staff that's ongoing between Diva and the ACO. Okay, thanks. So the other piece of 2018 that we thought we would highlight today is what we know about financial performance so far. And when I say so far, I mean January through July of 2018, we will be doing another quarterly report submission in December when we anticipate having another three months of information to share. This slide has our usual disclaimers about exercising caution when looking at early financial results. And I think we've mentioned those already. Just to jump ahead to the table, this table lists sort of at a high level some of the same categories that you would have seen in the year one results report and in the quarterly reports by quarter of 2018 and then year to date, which is those two quarters plus the month of July. You can look at the different categories but I think the high point to note is that the difference at that point in time for the 2018 performance year was approximately $410,000 overspent for the ACO. So that's about $410,000 more than the expected total cost of care through that point in the year. I think again, we're still struggling to find the right vocabulary for this. Diva has agreed with the ACO on a price to the, through the end of July, it's cost them about $400,000 more than the price. And so if the year it ended right there at that point in time, the ACO would have to write a check to the state for that $400,000. In preparation for this testimony, I took a closer peak at the financials. I would say as of the end of September, ACO spending is within 1% of target. And so it's really close. A word of caution on that, as Alicia said before, the claims run out means that after the calendar year ends, we typically receive claims for the next 90 days for ACO attributed members. So you should expect the ACO to be underspent, if anything, on a month-by-month basis. And then it adds up afterwards with those, that claims lag. So we'll keep track of it. What we're really looking for is big swings, right? Because big swings are a problem, likely for us in the ACO. We're not seeing them. We're still seeing spending that's generally tracking with the price that's set up front. Before you move on to 19, I had a question about the attribution, like the people who were attributed between 17 and 18. Are you, for the providers that were in the program for both years, are you seeing people continuing to be attributed or is there a big shift in that from year to year? I'd say there was more of a shift than we might have expected in 2017 to 2018. I don't have the percentage offhand, but there was a considerable percentage of the 2018 attributed population that was entirely new for the providers that had been participating in 2017 as well. Yeah, I would. That makes it complicated. Well, it's one of many things that have caused us to step back and check our assumptions. We want, the state wants to give providers predictability in this. As Alicia said, Diva was surprised at the lack of consistency between the cohorts in the first two years. And so now we're stepping back to say, one, what tools can we use to try to solve that problem? And two, well, what's the right level of consistency? Medicaid certainly has churn.  And so what does success look like from a predictability standpoint with Medicaid? And that likely may be different for commercial insurance and Medicare. And so we're still trying to test our assumptions around how much predictability we can really offer in an ACO program in Medicaid. Thank you. It's somewhat of a related question, but, and I'm sure that this is way too early for you to have the answer to this. So I'm just gonna plant the seed, curiosity seed. But I'm wondering when you're looking at 18 results, if you see, and I like your vocabulary, of less unnecessary care, do you see less unnecessary care in the HSAs where the payer mix, for example, is higher Medicaid relatively, thinking that these are potentially the critical mass needed to achieve the changes that we'd expect providers to start to be making, 30% of their panel has to be a particular alternative payment method, methodology before they start really changing their behavior. So I'm thinking in the HSAs that have a larger Medicaid mix, they've got a bigger chunk of their potential, they've got patients in this model, and, or the HSAs where this is now their second year in the model. So I'm wondering if there's learning going on, there's a big enough critical mass, are you seeing greater changes? And I know it's probably too early to tell but I'll just connect that curiosity seed. Thank you. It's an excellent question, and we're quite interested in it as well. That's why we're so grateful that the vast majority of hospitals in Vermont and health service areas are going to be in the program for 2019, thinking very particularly about, say, Springfield, which has a really high Medicaid mix and seeing whether this is going to have, that's gonna have a catalytic effect in Springfield, seeing the Northeast Kingdom come in as a group. It's really exciting, because before, even with the four health service areas that came in in 2017, we're very grateful to them, but they're really rooted around the Academic Medical Center in Chittenden County. And so it's hard to sort of tease out what's happening there because of this program and what's happening there because of other factors that are specific to the health network. So we are really grateful to have the opportunity to see other hospitals in action and to have some repeat performance to be able to start to figure out what's happening and why. And just from having sat through the hospital budget process now, obviously for many years or several years, some of the things they're talking about doing are clearly in direct response to being involved in the all-parent model. I mean, planting providers in school-based clinics in the Springfield area. I mean, these are obviously responses to the incentives that have been created by this model, so I'm curious to see how that goes. We're curious and we're also being mindful that the point of provider-led healthcare reform is that it's provider-led. So we're trying really hard as a payer not to be too prescriptive about what happens in each health service area. We wanna make sure that providers and Vermonters are really the focal point of healthcare innovation and that we as a payer are helping them achieve their full potential in that. But we're, like you, very likely anxious to find out what you're doing from whether those interventions work. So, and I think we'll talk about it a little more in 2019, but we keep asking ourselves the question of what's the role of local innovation in ACO-based reform? And so we think with some of the smaller community access hospitals that we might get a little bit of a peek in coming years of what innovation can happen in different health service areas. So your question is really meaningful to us. On the numbers that for your agreed upon payments, are the quarterly payments directly related to the seasonality? Well, there's certainly a seasonality in healthcare. The fixed perspective payments are basically equal. They're just paid out on a 112th basis for each month, but fee for service continues to have a seasonality towards it that would take the quarterly numbers and push them in certain directions. So what are the agreed upon payments for Q3 and Q4? Do you, I would say that they should mirror Q1 and Q2. They're gonna step down a little bit because we lose people over time, right? We set basically a member price per eligibility group. And then as we, some people leave the program over time that monthly payment drops a little bit, but it should be pretty consistent with the Q1 and Q2 payments you see up there on the chart. Okay, thank you. Yeah, on this chart, a couple of things. One, when you look at, so obviously the year to date is benefited by July. And that's why when we look at the total cost of care, you know, spend, overspend, it comes down. So one of the questions I have is when you look at this by HSA area, are you seeing anything, let's look at Q1 because if Q1's almost run out, you had a 742,000 overspend, yet there's a underspender, however we want to call it efficiency of a million nine on the shadow payments. But then I wonder when you look at it at HSA, are there things that pop out where some HSAs are representing most of that 742 and may in fact also be overspent on their fee for, you know, on their shadow payments? As the program expended from four health service areas to 10 health service areas in 2018, do we have 10 in 2018? Yep, thank you. We're still looking at it on a health service basis. I think we don't have, I don't think we've seen enough claims experience to be able to take a look at each HSA. I think that's gonna be part of our analysis going into 2019, though I defer to Alicia if she has more thoughts on it, because I know the reports include some data by HSA. I think for us though, it's important to realize that for the hospital service areas, you know, the patient mix matters, right? I mean, until we have stated another way, until we reached a point where all Medicaid members were in here, the mix of Medicaid members in the program really matters, and it's highly sort of correlated by HSA with the Academic Medical Center, and so we take a look at that, but you know, it's not clear to us yet what's happening in each HSA. Do you wanna talk more about that? I would agree with that, and I would say that I mentioned earlier on that we have several improvements to our financial reporting that we are targeting for the 2019 performance year, working with both the ACO and with DXC technologies to make sure that we can do that level of analysis on a more frequent basis. So we don't have a great answer for you today about this piece, but we do hope to have that information more readily available in future. Great, and one thing that would be really helpful on this chart as we move forward, you know, and get to Q3 when that comes in, I could see having a line, you know, let's look at Q1, you know, at the end of Q1, where were we on the over-underspent? Let's say it was 300,000 for just Q1, and now at the end of Q2, we're at 742,000, at the end of Q3, that could even go up a little bit more. I mean, I know you guys are tracking all of that, but to hit on your point of, you know, let's be careful because there's still, you know, six to nine months of claims that will come in against this, kind of seeing that trend, so when we get to Q4, we'll know where Q1 was at Q1, at Q2, at QQ, at Q4, something like that. Yeah, to me, I hear two really excellent questions in there, you know, and they strike right at the heart of what we're trying to do, which is to move from competent to run the program, to sophisticated in the way that we run the program. And one of the questions I hear is, and we're thinking hard about this with our actuaries and forecasters, is you should be able to come up with over time some sort of completion factor or incurred but not reported claims number that says, okay, as a general matter, after three months we're at this dollar amount and after six months we're at that dollar amount. And so as we get more experience, I think we'll get there. Particularly the higher the fixed perspective payment bucket gets, the easier that should be because you'll have less variability in fee for service claims. The other question in there, and it's way too early to tell, but it's a very good question is, what is the payment change doing, if anything, to resource allocation and healthcare utilization? Because one of the things that we thought about at the beginning of the program, probably like the board is, okay, if some providers get fixed perspective payments, do you start to see utilization pop up other places? The first place that we thought about that of course is prescription drugs, which are not in the program. You know, if you have a program that does not include prescription drugs, do you see a lot of prescription drugs spending somewhere else? We're not seeing a lot of that. We're seeing a little more of that, which is pretty reasonable if you have more primary care, but not enough to affect our balance sheet or to feel nervous about it. But we're gonna be doing the hard work of comparing providers that are inside the fixed perspective payment to those providers in health service areas that have less fixed perspective payment just to see if there's any utilization changes, to see if resource allocation is changing around the state. That's a question we're very concerned about and interested in as Medicaid. I'm sure the board's interested in it for Vermont as a whole across all payers. But those are two really, as we get better at this, we should be able to have a much better view into those two questions. 2019, just a couple of slides of update on where we are in our planning for a 2019 performance year. We are presently negotiating the contract for a 2019 performance year with one care at the start of our negotiation process. We identified a number of mutual goals. One was to minimize the number of programmatic changes from 2018 to 2019. I think that goes back to Michael's comment earlier about wanting to make sure that there's a certain amount of predictability for providers who are thinking about entering into new kinds of payment arrangements and that we're not changing too much at once that could potentially destabilize the model overall. Another focus was increasing the number of providers that were voluntarily participating in the model and thereby increase the number of Medicaid beneficiaries that would be attributed because of their relationships with those providers. And I think as we saw in the slide earlier, relative to growth of the program, we do have additional providers who have agreed to participate for a 2019 performance year and with those providers comes additional attribution of Medicaid members. And this goes back to, it just goes back to what we were talking about before. We want to be aggressive on behalf of our runners, but we don't want to be aggressive just for the sake of being aggressive. So far, Medicaid has tried to be a stable base for the ACO to work with commercial payers and Medicare. We're happy to continue to do that for a limited amount of time while the program gets up and running. And so that's really important to us. And I think so far, at least through two years, we've been good, sustainable, unpredictable partners on that. We are very pleased that the program continues to grow. When I think of this program, there's execution risk, which is just a fancy way of saying, can we run the program? So far, we're doing okay with that. But there are a couple of things out of our control. One is adoption risk. Are other people gonna join? Because an ACO is only as good as its members. We're very grateful to see the program go, and we're specifically very pleased to see federally qualified health centers join. That is where a lot of primary care happens in Vermont. And if you don't have enough primary care providers, the system will not work. So we're very pleased to see Community Health Center, Burlington and other folks join the model. It gives us some encouragement that this will continue to grow and start to be a more integrated health system, which is the point. The other risk beyond execution risk and adoption risk is just innovation risk. Are you gonna continue to have interventions that improve cost and quality for Vermonters? We're pleased that the Blueprint for Health and the ACO and others continue to work together on primary care innovation in Vermont. But I think we keep pushing the ACO to say, hey, what's gonna be different? We know that what we're doing different, which is paying differently and monitoring quality differently, but we wanna keep pushing them to tell us what's different on the ground and what's gonna be different for providers as they help care for Vermonters. What tools do you have for ensuring that the problematic alignment? Sure, so one of the things that we try to do every time we consider a different adjustment to the program is understand what it looks like in the Medicare agreement and the commercial agreement. And I think we started with a significant amount of alignment with the Medicare program because in 2016 when we were developing our framework for the Vermont Medicaid Next Generation Program, we essentially started with the Medicare Next Generation terms and modified them a little bit where appropriate for a Medicaid membership. Blue Cross, I believe, also looked at both the Medicaid program and the Medicare program when establishing their program terms. And so we felt pretty good about our programmatic alignment for going into the 2018 performance year. And then our objectives for both 2019, as I just mentioned, and previously for the 2018 performance year were minimizing those areas where there might be difference. We do have a couple of areas where we do have differences from the other payer programs that we think are innovative and worth deviating from those other payer programs. And I think one of those areas that we could mention is in our waiver of prior authorizations. I'd say that there's still a lot more that we need to learn about the waiver of prior authorizations and how best to operationalize it. But it is an area that makes the Medicaid program distinct and we think that it's worth continuing having that difference. This is a little bit low-tech, but one of the biggest ways we do this is just by talking to each other. There's a Newland Journal of Medicine article about what's next in payment delivery system reform that came out in September and it encouraged payers to collaborate more. We spend a considerable amount of time talking to Kelly Lange and her folks at Blue Cross Blue Shield about their ACO program. We spend time on the phone with CMMI talking about the Medicare piece of the program just to make sure that we're asking for things and talking about things in consistent ways to try to make sure we're truly moving towards an integrated system as opposed to everybody asking for their own silo in the ACO program. And so far that's worked out that this has been good communication. I think we can probably think of more actionable things to do in that collaboration, but so far it's been good just to talk through common issues that we have as payers in dealing with the ACO. So two areas of programmatic change that we do have highlighted for a 2019 performance here relate to attribution and the waiver of prior authorization. Around attribution, we wanted to make some adjustments to the methodology that we have been using for prospective attribution to see if we can make it continue to align with other payers attribution methodologies, but also recognizing that we probably had areas for improvement. The one area where we really focused on improvement potential for this year was extending our historic look back period from two years or 24 months to two and a half years or 30 months. We also did a fair amount of work with OneCare this year in preparation for 2019 to really clean up our attribution methodology and make sure it was working as intended, which was some sort of detailed examination of the evaluation and management codes that are used to identify primary care relationships, the indicators that we use to identify types of primary care providers. It was pretty technical, but we felt like it was a good time for us to be doing that review to make sure that the methodology was, one, working as intended and, two, producing the results that we were hoping to see. The other thing that we focused on beyond just looking at the technical piece of our attribution methodology, as Michael mentioned, was to start to do some thinking about innovation in attribution, ways that we could start to look at attribution beyond just a historic relationship with a primary care provider. As Michael mentioned, we're still in the thought phase, but we do hope we'll have some additional information that we can share about that within the coming month. Yeah, I mean, as you know, this can get as complicated as you want to get, but the three basic questions are, where are our people? Where's our money? How are we doing? And where is our people? I'm really proud of Diva working with the ACO and providers just to listen, because the way this feedback gets to us is that a practice will submit who it thinks should be in the ACO program, it gets to us, and then lots of those people don't show up in the attribution methodology. And then a practice will say to us, we just don't understand, where did these people go? And so we've, Diva has put in what the ACO several years of effort of trying to figure out, okay, when you inspected this for monitor to be part of this program, it didn't happen, why? And just trying to go through the work of just patching holes in the attribution methodology and patching our technical execution and attribution methodology to make sure you can find our people and put them in. Because we think there's a real desire on behalf of the ACO providers to really operate the Medicaid program in the same way and trying to get as close as we can to having that everybody in that Medicaid cohort be treated the exact same way. And so people can practice medicine in a uniform way across their Medicaid panel. And so we've put in a lot of work on that in prior authorization, but most importantly, we've just listened to try to see it from the perspective of providers and then change our operations and so it works better for providers. And we're gonna keep doing that in this program until we get it right. Mr. Good question about that. In terms of the additional numbers of Medicaid patients that are largely, I can imagine, I think, stands to be from 10 hospital service areas and 13, but I'm wondering what is the marginal impact of just the attribution methodology changing? How many people do you think are at your adage about what is the difference from that? I'm hoping I'm gonna look back. That's a great question and we do have some summary information. I don't have the numbers off hand, but I'd be happy to share that. Thank you. Do you have any questions, Marie? Yeah, I had another question on, can you go back to slide 15 for a minute? And just wanted to talk a little bit about, let's assume for just this discussion that this were actual numbers for the year, the year was over and we'd had our six months or nine months to catch up on claims. And when you look at the shadow underspend there of 5.5 million, what I interpreted you were saying before is eventually the actuaries would take that into consideration and that may roll forward. A question or concern I have about that, and I'm not sure how this factors in, is when we look at the hospitals, and that's particularly all going through the hospitals, when we look at a charge at a hospital of $100, commercial will reimburse at about 70%, Medicaid will reimburse at about 30 to 30%, maybe 25 to 40% depending on Medicare, maybe slightly higher. And a hospital makes 2% at the bottom line, 2 to 3%. So what we're not factoring anywhere in and I'm not sure how we do, if we can benefit from that is cost. So I understand there's obviously, we're not seeing the shadow fee for service tying in, but at some point is there a way to help with that cost shift or cost change? Because if we were to assume that if the cost was 100 bucks and you had a $70 at the commercial and you have a $30 at Medicaid and those were the only two payers and the hospital's making two or 3%, it's obviously not capturing that cost. And so I'm not sure, this is the appropriate place to look at that, but I'm just saying, is there a way to throw that in at all? We've generally taken the approach at Diva that we set our ACO rates based on our present fee for service rates, right? And stay out of the question of whether those rates were sufficient as a separate question here. There's been nothing about the operation of the ACO program that's changed that so far. And we're probably not going to wander down into that conversation in the near future. I think in a world where you have, if you imagine an ACO program in Vermont that is fully at scale, I think the type of price disparities that you're describing would become really clear, right? Just in the per member per month price by payer and it would naturally prompt a really good conversation about what the right level of reimbursement is across payers. Thanks. First of all, I wanna thank you for really taking a leadership role in terms of not only improving the operation of your program, but also in being forward thinking in terms of ways to continue to innovate. And I would also say that we have a timing challenge in that I know your work is driven by the September 30th provider deadline and that you work really hard to turn that around and get us the information that we need through the Medicaid rate case as soon as you can, but it really puts us in a bad spot in terms of our ACO budget review when we don't have final information. And it's not just you guys, you just happen to be sitting here. In fact, you are joined by all payers in this. And we're not gonna solve it for this year's budget, but I just wanna express that I think we need to take a serious look at the timing because and just at a staff level have a rigorous conversation about what's realistic and moving forward because we're in kind of the same space this year that we were last year and I really don't want us to be there again next year. So I just wanted to take the opportunity to say thank you and also I would really appreciate trying to work with our staff on solving that problem. So thank you for your encouragement of Diva as an innovator. We agree with you on the timing. It is really difficult and Diva appreciates the position the board's in and we're happy to work with your staff to see if we can make improvements. I think just in the spirit of full transparency, the larger the ACO program gets, the larger the risk that mispricing it would cause a problem with Diva's budget and the state's budget. And so there's some discomfort with speeding up. So I think we probably need to rethink the timing overall because we'd rather be right than fast, but I really appreciate the box the board finds itself in with the ACO budget, but we're happy to work with you on it. Thank you. Okay, other questions or comments from the board? If not, we'll open it up to the public for questions or comments. Susan. Could you put up the slide with the value-based payment, who's on this chart? The performance. So I've got a couple of questions about this. Mike, I know one asked about this in the past, but I have a couple of questions about the program going forward. But can you clarify, the columns that have the NA not applicable, those are measures for which there were no national benchmark, correct? That is correct. And the ACO received points for those. Were those points, were they paid? Well, let me just stop it. They received points. So how many of the measures did they get points for when there were no benchmark? So in our 2017 agreement with OneCare, we determined that there would not be national benchmarks for, you can see four of the 10 payment measures that are there for the 2017 performance here. Because no benchmarks were going to be available for the first year of the program, we mirrored the next generation model from Medicare by saying that we would award essentially full credit or payment for reporting for those measures for the 2017 performance here with the expectation that points would be awarded based on performance relative to either national benchmarks or prior year performance in subsequent years. Just a reminder that during public comment period, it's a period for public comment and if there's anything that's directed, it should be directed through us. Oh, okay, I'm sorry. Could you ask whether or not it was known when they selected these measures that there were for 40% of them, there weren't going to be benchmarks, but they were going to get full credit for 40% of their payment. Payment for value was going to be based on those benchmarks. Did they know that at the outset? Are you going to answer that? I am, yes. Yes, we did know at the time of contract signature for the first performance year that four of these measures would not have national benchmarks for 2017. We're currently in for 2018 and for the one that's being negotiated for 2019. For the 2018 performance year, where national benchmarks exist, we will use those to award points to the ACO based on their performance and where national benchmarks continue to be unavailable for the 2018 performance year, results will be compared to the ACO's performance in the 2017 performance year. Have those four measures, whether or not any of them have benchmarks now? I would have to check on that. I believe at least two of them should have national benchmarks for the 2018 performance year. Just to step back for a second, one of the things that we talked about at AHS is that the ACO program and payment reform are not the same thing. We are engaged in payment reform across the agency and at DEVA. Presently, we have our ACO program. We are working on a mental health case rate, a developmental disability services payment reform project, ABA services, which is autism payment reform project. And this follows that general incremental trend that I was talking about earlier, which is you start out measuring things, then you start after measuring and reporting, you compare yourself to a benchmark and then you get more aggressive on the benchmark. So you should expect, for example, in our mental health payment reform, that some of the quality measures at first will just simply be reporting. Getting providers in a place where they understand that you have to report something to get paid and then be more aggressive over time. So that's here in the ACO contract, but it's also in other payment reforms that DEVA has under development and plans to implement. Is there other public comment? I see a question for the board. This particular chart, I believe, would have put us, should have been submitted with one parent's budget submission in that they're required to submit their quality performance results for all their current payers. And I did not see in one parent's materials performance measures or performance report for their Medicaid next generation. And so I would just ask you, if you haven't received this from one parent to just add that to your materials for one care project. I mean, I own double check with the secretary that was this in the report that was submitted as part of the report? It was. Mike Marver is here checking his head, yes. And that was submitted directly to the board. So we are in position. From one parent? What I'm going to say is one parent has a positive obligation of going as to reporting a burden to submit their performance results. And I don't think one parent has submitted their Medicaid performance results. I know they submitted their Medicare scorecard after the batch and they submitted some results from Blue Cross and Keele, but I've not seen one parent. This was submitted by one care. By one care? Yes. Can you, okay. If someone's been emailed this room, it was. Well, we can send that to you, but you do have it now and it was submitted. And just one more point on the measures that did not have national benchmarks that were included in our 2017 performance year contract. Those were measures that were selected to align with the all-pair model agreement measures. And I think we knew that we wouldn't have benchmarks at least for the 2017 performance year. Is there other public comment? Seeing none, I want to thank you both for a very thorough presentation. Thank you very much. All of us at the Free Mountain Care Board have a great Thanksgiving holiday. Thank you. We are very excited at my house for dessert quality measures. And we'll report back to the board when we can. I always volunteer to be the taste tester. Okay, is there any old business to come before the board? Seeing none, is there any new business to come before the board? Seeing none, is there a motion to adjourn? Second. It's been moved and seconded to adjourn. All those in agreement signify by saying aye. Aye. Any opposed? Thank you everyone and happy Thanksgiving.