he Medicare program because of the risk as we talked about earlier, but I was just curious how you are thinking that will impact their broader participation in the ACO model if you have concerns about the bankruptcy related to the financial relationship that you've had with Springfield or any other information that you think we should be aware of. So that's a great question. And we had a series of discussions with Springfield, both hospital and FQHC prior to having to turn and what our provider rosters would be for the payers because as you know, with Medicare, once you submit your roster, that's it. There's no new ads. So we wanted to make sure that we had some thoughtful dialogue about the next steps and approaches. And in talking with the leadership at Springfield, they felt like the program in and of itself was very valuable in terms of having the predictability with the Medicaid payments and moving to something similar with the Medicare program. I mean, the commercial program, the risk for the Medicare program was, as you said, too high for the hospital. And so what we've been doing is having some discussions with the FQHC to say really, primary care is foundational to the work that we do. We don't want you to lose momentum and the work that you're already doing. So let's have some discussions to see how we can continue to support in advance that work so that when you're able to move back into a Medicare program, you can be successful and not lose ground. No, I mean, just to say that we pay attention closely to the 2019 performance to make sure that we don't have any major risks for one care. So we're trying to balance, let's support Springfield, give them what they need, but also look out for one care in its network, too. So we take close attention to that. Thank you. Related to the complex care management program and the shift in the payments, I just wanted to clarify some things that to make sure that my understanding is correct. So for new providers coming into the program, in order to give them this initial year of capacity building, will they be receiving the funds that were the same payments as everybody received this year, so the $15, et cetera? Yes, so what we will do is apply the formulas we use today to their entire pioneering hybrid populations portionally to give them that onboarding opportunity. Great. That's what I thought, but in terms of, so one of the investments, and this is on page 43 of section five of your original submission, is around primary care engagement and looking at how to engage for monthers more proactively. And I think that refers to the Blue Cross Blue Shield program around primary care that is to be new, where it's not a scale target model, but it allows for engagement with folks in the QHP population who otherwise haven't engaged in primary care. It's really taking the foundational work that we've been doing under that non-scale target eligible program and looking at how we could expand it in new ways. So we are thinking about, for example, how we could resource communities around some innovative ideas to promote access if we expand the Medicaid geographic attribution pilot for example, because we know these are individuals that don't have a relationship with primary care, otherwise they would have already been in the model. I'll add one other point. It's a nice, tangible geographic attribution as well, where we may be attributing lives to our model that don't have an active primary care relationship, and this work could help get them engaged with primary care. Great. On the Innovation Fund, I was very interested to see that you had created an Innovation Fund. We had done this with our state innovation model grant, which I thought was one of the parts of the grant that providers really appreciated, and it did allow us to test some really cool innovations, and some of them worked well and some of those didn't. So one of the questions I had about the Innovation Fund is how you would be looking at evaluating each of the projects that you're funding. What's your timeframe for that? That may vary by project, but just giving us a general sense of we're investing in these cool things, but then what? Sure. So as part of the structured request for proposal process that we ran two rounds, we were very clear at the direction of our Population Health Strategy Committee of what the areas of focus interest were. So that was the framework for receiving applications, and then in the applications themselves, they had to answer questions about what the core measures would be, and we found that through follow-up conversation with the sites that were preliminarily selected that they often needed to do some work to refine some of that to get really feasible about can you actually ask that many survey questions or that frequently, for example. And so what we've done is we've structured a process that first of all, we believe that anything that was funded has a high likelihood of success and has the potential to both be scaled to other sites and sustainable within those settings. But then beyond that, in their first quarter was deliverable to us, they have a final evaluation plan due. And so those are the metrics that we will be monitoring. Many times the sites themselves collect the data, but other times they were very explicit with us up front that they needed to support or claims data information that we had access to, and so we will partner with them on those analyses. Thank you. I had mentioned briefly in your presentation today and also had discussed it in section five of your submission around the DIVA Medicaid Prior Authorization Waiver, and I know that last year there were some changes to that to further allow, to make it less administratively burdensome on providers. Are you still looking to do some further refinements? How's that going? Are you seeing providers appreciating the reduction in administrative burden and could you speak to that a little bit in a little more depth? Sure. That's another great question. We have definitely seen an evolution of the benefit to providers as we remove some of the prior authorization requirements and who they're removed for over the course of the last two and a half years that we've been working with the program. And so as we continue to have discussions with Medicaid about the geographic attribution and starts to push the envelope of why not do this for the entire Medicaid population? And so I think it's gonna be a delicate balance of what the penetration that's needed for the Medicaid program to say we're gonna go ahead and say we're gonna lift it for our entire Medicaid population. And so I think those are the discussions that we're having right now to look at what the benefits would be and that we would continue to be able to receive enough data and information to tell Medicaid, okay, this is how it's looking in terms of trends that require prior authorization. Things that require prior authorization is going up. Are they going down? Are they staying steady so that they can continue to evaluate the model? I'm getting the eye from the chair. In your answers to our questions, see I'm all out of the binder. We've gone to the supplemental material. We've asked you a question about churn or turnover in attributed lives by a payor so thank you for providing that. That information is particularly interesting to me because I would expect that when you have a new patient who's come into the model, it's often because it's a new provider coming into the model or it may be a patient who's just engaging in the primary care under some of the new programs. But it does sort of call the question of making it difficult to evaluate, for example, quality metrics year over year when you have a constantly shifting population. And so I was wondering if it's possible for you to, from what you know about the provider changes, to look at the new patient year over year and figure out how much of that is driven by new providers participating. I know you don't know necessarily things like changes in enrollment, but if the pieces that you can quantify, that would be interesting and helpful in terms, for me at least, in terms of trying to evaluate the quality metrics and what we need to do is we're looking at the program. And that's not something you have to answer right now, but if that's something that you might be able to share more depth on, and I would at least appreciate that. I think you definitely do that, right? Great. And then my last question is, actually I have two, I'm sorry, Kevin. We had asked you about clinical priorities by HSA, and I certainly understand that because the clinical priorities are set at the community health team or the accountable community for health level, then your window to that is the regional clinical representative. And that really a lot of those clinical priorities are still being set through what we would have called the blueprint for health prior to the ACO, since the ACO is required by statute to build on top of the blueprint. I think it gets a little confusing sometimes because you're supposed to be working hand in glove and I at least think I've seen a lot of improvement in that over the last couple of years. But do you happen to know if the blueprint tracks all those activities at the HSA level and obviously you're not answerable to the blueprint, but if you know, I was just curious. I don't know the answer to that. I'm sure there's anti-double information, but I don't know if it's systematic. Okay, thank you. I wanted to get an update on the status of your contract with the ambulatory surgical center and the payment model that you're negotiating with. So the ambulatory surgery center has submitted a contract to be part of the programs. What we said, what our conversations was with them was that we needed to get some history because the surgery center had just opened up to be able to evaluate what would be the next type of payment model. So for 2020, 2021, I'm always like, we're always operating one year like lag and advance, so sometimes they're not alert and oriented time speeds. So for 2021, will we evaluate that for them? And then lastly, do you have any updates, sorry though, on when you're expecting your care contracts to be finalized, particularly for the two new programs that we don't have a lot of information? So the plan right now is for the, both the MVP and the Blue Frost Booth Shield program to go to our board in November. Obviously December is the last date that we could get signatures to be able to go into effect for January. But our plan right now is to have those go to the board in November. Thank you. Okay, Marie. Laura, I think you're going to check. I apologize for not being there in the lecture that you did earlier. I had that long day of my calendar. I want to talk about the grid and basically understand the formula dollars that you have budgeted in a lot of areas about the currency. In the response to the questions that you sent out, you said that now the hospitals, I'm sorry, Maureen, could you speak up? I can't hear you. Oh, sure. Oh, he got it, okay. I love the question. Okay, you got that one? Oh, sure. Good job. Okay, is that okay now? Yes. Okay. I can hear Kevin with the question. Yeah. Okay, so on the risk mitigation piece, it looks like you're now saying that four money dollars is going to be backed up by UDM Dartmouth. And first I want to clarify if that's true. So the switch we're making in 2020 is that the founders, Dartmouth and Indian Medical Center, will be the backs up for the specific risk mitigation agreements, which are that four million dollar ballpark, which really means that one care is not retaining any risk that would otherwise be delegated to the network anymore. And the remaining reserves that we keep at one care are specifically to cover what I think I've asked, one care risks. And the example I used in the narrative in the question response was we have a hospital that owes an obligation as part of settlement, but either cannot or will not pay. And we still need to write that check to the payer. So it's some reserve for that. The other reason I like to have some reserves on the one care books is our balance sheet has so much cash flow throughput that just having a little bit of liquidity on the balance sheet helps make sure that I can make good on payments and like a timing of contracts and when we actually receive payments for any of our payer relationships or state awards. So that's really why having some reserves left at one care to me is an important strategy, but all the risk is fully delegated either to the network or to the founders in this particular case for those specific risk mitigation agreements. Does that answer your question? Yeah, it does answer my question. In the past, we had put up enough reserves to cover some of the risk mitigation issues at the hospital that you were covering and you had talked about that. Other than in the answer to one of the questions that we have, you really didn't talk too much about this shift, which is a fairly big shift in the reserve policy. And I think it actually is that a little yes for the ACM before you do one care because we no longer have to take that little responsibility. But that was a shift and I was a little concerned with what it said about covering the settlement obligation because we really haven't talked necessarily about covering settlement obligations or possible that couldn't do that beyond the four million risk mitigation. I mean, that couldn't carry the rabbit significance and didn't know why that was not going to connect because I didn't understand that as being part of what you were going to use the risk reserves for. Maybe I'm going to interpret that. No, I mean, I think you captured it right. But beyond the four million, you're right. If we have a bigger risk obligation of one of our network participants pose and they cannot make good on that payment, it is a bigger problem. There is a provision in our operator group with the founders, which is really the ultimate backstop, but I don't want to have to use that. That should be a last resort or really something went awry and we need to go with that layer. So this is just having some reasonable reserves at one care in case another circumstance comes up in which the ability to make good on a settlement obligation is in question. Okay. And then continuing on with the risk, we know that for the hospitals reserving the risk has been a bit of a concern. And I think we've applied 34 states reserving the risk is essential to sustainability of two sides of accountability program. And just wondering, you know, how are you going to be monitoring and what guidance are you giving the hospitals that are bearing the risk about that reserving? Really good question. And one I hope to improve upon next year, as we just have more years of experience in the programs, but I think a really important distinguishing factor is the portion of risk that I think of as new risk versus their old risk. It's really helpful for many of these organizations. Everybody had risk in fever service. If you just had low volumes or you lose one of your top billers, your revenue is going to be affected. That remains, but when the hospitals take on risk for services outside of their own walls, that's brand new risk to me. And I think that they should be able to reasonably plan for some sort of a risk payment in that particular space. So that's one of the new ways that I anticipate slicing risk in the future to itemize it a little bit more clearly. And then this links in with the questions earlier about the risk model in total and making sure that it's, because in balance with each of the participating hospitals and that it's really the right incentive, the right size incentive to help move us on this path and not excessive. And then one comment I would have for future presentation would be really putting a full financial statement in the presentation. I know we've had it in our backup. And I think it's good for everybody to see both the full income statement, including all of the payments from all payers and then what you pay out. And then you touched upon the cash flow potential issues depending on when you get payment from the payers and when you have to pay things out. But I think anything on cash flow or balance sheet that you'd like to bring up because we didn't see that presented today. Yep, fair point. Do you have any cash flow issues with part timing, if you're experiencing this year? I know there was some issues with one of the payers at one point with settlement. And I just wanted to know if you had any concerns there because obviously your responsibility is to pay out to the hospital or maybe if you're covering their cost that you need to be getting the receipts in from the payers. Generally speaking, we haven't had significant cash flow issues. The very first month of our Medicare program was the only month in which we didn't actually receive the AIPVP payment. So the biggest risk, even though we haven't had big problems to date, the biggest risk is that there would be some sort of a problem for one care, getting its monthly fixed payment allocation from any of the payers. And generally speaking, they've all been relatively on time, a couple of maybe one week delays that we can manage. But if we had any sustained delay in those hospital fixed payments coming into one care, we could have cash flow issues downstream pretty fast. And that's a worry that we should all share. And other than that, it hasn't been too big of a problem. I mean, the clients processing issues in that space are not one care cash flow issues, but they affect cash in the providers. And if you have to choose between providers being double paid or zero paid for their work, you choose double, but it's, you know, you pick your poison really. So that's another area that I'd like to see fewer problems in the future, but the biggest risk is the time in those fixed payments. Okay, and those are also starting to give me answers to the question on going high churn rate for 2018 to 2019, and 15% for Medicare, 21% for Medicaid, and 38% for the hospital shield on exchange. And, you know, in a market where we're trying to grow the churn rate between the lives, and when we don't really have a lot of players that think that the churn rate seems high going from 18 to 19, and you know, I know part of it is student providers are, but we're adding more providers, and do you think of that in the explanation where it's a large churn rate from 18 to 19? I think the payers can speak to this really well, but just my experience as far as if there's just a lot of churn in general in coverage, particularly in Medicaid and particularly in the QHP lines. I think you see more stability in Medicare and some of the self-funded plans, employer-based plans, but here's what payers would say, but I would imagine they'd say yeah, you should expect this kind of churn on kind of an ongoing basis. Our network configuration will affect that a little bit, so as we have some stable years, maybe we see a little bit less churn. But I think it's something we should all expect in the future, I don't anticipate it really going away unless we have the whole state, and it's really just people coming, you know, kind of switching between products rather than being added in for the first time. Okay, I'm now in the state funding, and this is the very beginning of the presentation, so you may have addressed this, but on 13.1 million, and I heard your explanation about some of this, I think you're just redirecting from Medicaid, like 5.3 million, some of it are continuation programs, and then about 5 million is new, and some of it could be matched with federal money, but if you were to estimate if there were the potential risk to the funding source, how much would it be? I think there would be not more than 15 million. Well, certainly the, I mean, any of the new funding that we're asking for, I think would be in front of the highest risk area, the, that's the 7.8 million in total DSR, that's included in the 2020 budget. I think less risky, but not without risk, is the health information technology. I say it's less risky just because the match rate for the state of Vermont is so favorable, it's a 90-10 match pool, but that's ultimately not a decision. And then the amount of the one-care-fix payment allocation, that's a choice that we make in partnership with Divo when we're developing our program design, but we have some voice at the table when we make that decision to move those dollars to that bucket, so really the highest risk is that we just don't receive the 7.8 million in DSR, six of which is really the new pool. Okay, and then just one last question on the risk model. Are we looking at, or do you think in the near future, we'll see any alternatives to how the risk will be given to each hospital, particularly where we see hospitals that have less of their care being done in their hospital and more being done in other hospitals within the ACO or entirely outside, they'd have a larger percentage of risk to what they actually receive for FTP, and clearly that's gonna grow as we grow the attributed lives and could create even a larger barrier for these hospitals. So just wondering what the risk is, on industry, and we've talked a little bit about this before on industry, we want the HSA hospital to bear the risk for those patients, but it becomes harder and harder if most of their care or a large percentage of their care is done elsewhere, and it can be a significant, I mean it can be more than their operating margins at these hospitals, particularly when some of them lose money, but that's a separate issue, you know, I feel like this is a huge risk. I agree, and there's a lot of nuances here, I mean I have personal thoughts about things I want to explore with the network, but it really doesn't need to be a network decision, so I don't want to get out too far out in front, we do need to go through a process to evaluate, but I'll just give an example of a couple of the things I think about. Yes, we could take the hospitals that tend to refer more out and give the risk to the hospital and the community that actually provided care, but I worry about the incentive that creates to start referring more care out as a means to avoid that risk, and there's a lot of nuance in this space, and it's a very Newtonian exercise to go through as well, to really understand if we do this, what might a recipient of the other end then do in response to this, and we want to make sure that the decisions we make support our network participants and their financial health, that's a primary goal, but also support the goals of the ACO in terms of really the reward that can be received from efficient, high quality care, so it's a complicated topic area, and like I said earlier in the presentation, we want to spend a significant amount of time on it in the first few months of 2020. Okay, great, thank you, okay. So we've been able to negotiate to stay in the room until five, if we've not done it five, then we'll adjourn the meeting and come back next Wednesday, and the healthcare advocate has already indicated to me that out of respect to people that travel, he would defer questions if we're getting close to that five o'clock timeframe until next week. I will do the same with my questions, that's what's necessary, but if at all possible, it would be really good if we could get this done in the next hour, so with that, I'm turning it over to Jess. I have to start with my question. Did you remember that I wait for the next week for my questions? All right, well thank you very much. So I think about innovation, and I think about constant iteration that it comes with innovation, navigating unforeseen obstacles, restarts and redirections happen all the time. One care, as you mentioned, Vicki, has been the subject of some criticism in recent weeks. And in the spirit of honest self-reflection, I'm wondering if you can think about which of that criticism of either your structure or your performance is justified and how this budget addresses some of those criticisms that are justified, and then what criticisms are unjustified and why? My 40,000 foot question, then I'm going to be exactly right. I'm going to take a stab at it. We try really hard in this budget testimony as we were setting things up to really try to address many of the inaccurate, or I'll call them partial truths and criticisms about one care of Vermont, and that were in certain publications over the last three or four weeks. And I do believe that we have set the record straight on many of those inaccuracies. The subject of whether or not we're losing money, no, that's not accurate statement, is our operating budget really, $13.6 million. We covered that at the beginning of the presentation. It's not $13.6 million. And I think the other piece, a billion, billion, billion dollars, it's like, thank you, Tom, money guy. And no, we're not requesting an additional $13.1 million from the state. I think those were the biggest things that I really want to correct the record on. I think Sarah's done a really good job talking about how we're doing overall in quality and we're not, our providers are not failing in terms of our overall quality measures and how we're doing on those outcomes, as well as the progress to date that we've been making as a delivery system. And I think one of the big takeaways is that when we come before you next year, it shouldn't be a big surprise or it shouldn't be another factor that that number is going to grow because the absolute purpose of the all-pair model is to really have that additional individuals and the monitors covered under a value-based system of care and not in the fee-for-service. To follow up on Maureen's question about the risk of the new funding, that DSR funding is about $7.8 million, would be the potentially at-risk funding to get it. Do you have a sense of which programs you would cut if that funding did not come in? I think it's back to, in Tom's budget presentation, we've had recent discussions with the Agency of Human Services and understand that this would likely be a budget adjustment. So we'll definitely have to go back and circle around to say what kind of programs we're going to defer until we know that that funding is secured and those are discussions that we'll be having with our board over the next few months. When you talk about that recent change in the risk mitigation plan, shifting some of that risk from one care to the founders, we talked about that risk mitigation now lying between UDM and Dartmouth-Fishcock. Is it 50-50 or is it not 50-50 in terms of the risk that each entity is led? We've been actually finalized, but I think the initial thought on that is that it would be 50-50? One of the things we did ask for, which I was disappointed enough to see was the one care Vermont variation in care houses. We got the mock-up, but we didn't actually get the data. And we specifically asked for the underlying data because it helps us understand where are the areas of high cost across our geographic communities and where are the areas where there could be more improvement in health outcomes. And the reason that that's important is because you're making millions of dollars of investments across the entire state of Vermont, and it would help us understand are those investments impactful investments to go to understand what are the differences, geographic differences, and variations in health outcomes. It helps us understand these investments make sense given what we're seeing in the variation of care reports. So I'm wondering if it's possible for you to actually provide us the actual reports beyond a mock-up of what it is. Yeah, so we can speak to that a little bit. I think it's an opportunity for us to engage with our legal advisors on both sides to discuss how we could do that. I think to be very transparent, our concern is that that information is sensitive and changes frequently and could be easily misconstrued in the public domain and that that is not fair to our hospitals or our communities that are doing so much hard work to try to transform care delivery. So I think if we set some context for that, we can find a way to meet somewhere in the middle around sharing some of that information. Okay, thank you. About the comprehensive payment and form investment, it's gone down. I'm wondering if you can talk about that in this year's budget relative to prior year's budget. We modeled over a year to be reflective of the participants and one of the changes this year is we had a partial capitation model in the last year's budget and felt like that was a nice one year unwrapped but really the idea is a more holistic payment of work for these practices. So we are no longer offering that partial capitation model which means that there's actually fewer total participating but more in the full cap. So that's the more robust or model and we just adjust that amount to be reflected on what we think it's gonna cost to deliver the comprehensive payment form model to those practices. So it's not actually less investment it just matters to the cost. And now to be brief I'm gonna have one more question.  So we might all share this a little bit but I can certainly speak in the finance space. Some of the increased FTEs is actually conversion of areas where we rely on contracts and are now realizing we need full time commitment in these particular areas so there's a couple of those examples in the finance space and as well as the legal. I can speak to the finance team is the one that I know most intimately. A lot of demands, good demands from the network coming in right now, good questions about understanding their performance, wanting to know more about their opportunities. So bolstering the really the finance analytics capacity to be able to answer those questions on behalf of the network. I'm also really looking forward to being a little bit more directly engaged with the finance teams into our pretty good risk-bearing hospitals in the future and wanted to staff up accordingly there. In more of the financial management and accounting space, we have some growth in that arena as well. Our business is becoming more and more complicated as we have more program, more payer partnerships, more communities, more investment areas and vehicles and we just need to make sure we have the right staff and the right capacity to manage all of those new initiatives and make sure that we have the house in order to speak. So just briefly I would add to that on the analytics side we're really trying to focus more in-depth on accepting new payer data and recognizing that that creates new demands for ingesting, processing, validating that information turning it around. And then on the evaluation side as we spoke to earlier, really making sure that we have robust approaches to analyze the impact of the direct investments programs that we're offering to make those critical decisions about what to continue and what they need to stop. And I would say the last piece when Todd Lamar, previous CEO, decided to move on a conscious decision was made by our board to have a full-time CEO that didn't also have responsibilities for the Adirondack ACO UVM Medical Center and that also had an effect on other leadership positions. Our VP of Finance or now our CFO will be a full-time person where it was previously split before we had other leadership positions within the organization that we're also shared with the Adirondack ACO. So those humanatively add up some additional looking FTEs as part of one of the CARES budget but in looking at where we are in the evolution of our model, we really felt like that commitment was necessary. Can we ask anyone who's on the phone please view their side? That is all I have. I do want to thank you. I know a lot of Harvard students who are presenting and building your budget and also all Harvard graduates and all of them, I appreciate it. Thank you. Thank you, Jess. So I just want to do a couple of quick follow-up questions. You talked about the 20 additional positions and on your work chart, it looks like you've added a new member to the C suite. Is that correct? No, so we previously had a Vice President of Finance and Strategy and that was the position that was split between Adirondack ACO and one CARE Vermont. We simply converted that into a full-time CFO position. And what is the cost of that position? What is the time frame for building it? So we are currently had that position posted and it's in compensation right now and we'd be happy to follow up with you on those facts once we receive them. And obviously congratulations on your elevation and Sarah on your elevation and Sarah's post creates another vacancy on your work chart. And so if these positions are filled before the start of the fiscal year do you invest those savings into population or health or what will you do with those dollars if they're not? Good question. We have vacancy savings. We've had vacancy savings basically over a year as we've grown and just it comes with a growth enterprise like this. And any decisions about under spending of expenses will just have to be taken into context without all the other moving parts within the organization. And we've reached the end of the year and had let's say a substantial gain on the books due to vacancy savings. It would be a decision for our board really to evaluate what's the right step to issue credits back to those who do throughout the year to be reinvest them in different programs. There's a handful of different options we can consider. Are you committed to meeting the obligations that the state of Vermont has agreed to under the all fair model of financial tardings? I am committed to making sure that the one care budget model that we produce every year aims to further the goals of the all fair model and that 3.5%. We're just a piece of the slice you saw in that slide. But what we produce every year, we intend to be furthering the goals of the all fair model and its financial goals. And are you convinced at this time that the costs of the one care organization will be less than the savings that you're going through the system? I was going to say that's a sustainability plan is that we have to find a way to be able to continuously keep up these programs as we grow attribution and to balance the staffing ratios that we have right now so that we can continue under this model. So in your submission, you show us that you've reduced the percentage of the total from 1.77 to 1.4. What's your ultimate goal for what your cost should be as a percentage of the overall? I'm not sure if we have an ultimate goal, but it's really to find the balance of making the right investments, having the right ACL level supports with what the network needs. And I think over time, what we'd hope to see is that the work that we need to kind of push out into the network becomes ingrained in our healthcare landscape and we don't need to necessarily facilitate that so heavily anymore. And that I think can stabilize a lot of the work, but I think there's always going to be some value that the ACL can bring in terms of particular data and analytics and warehousing at that central location and some of the finance and contracting functions we've fulfilled and execute all these contracts. So I'm not sure if there's a set number to say this is where we want it to be, but it's when we evaluate every year of the model and determine what the needs of the network are and how we continue to meet the needs of the alternate model. You talked about some of the things that you're going to be focusing on in the upcoming year and I was especially happy to hear about the focus on chronic illness and the type of basically care coordination that could occur there to reduce costs. Many people have argued that you've got the low hanging through what's been focused on the Medicaid and Medicare population and those are the populations that certainly would best be managed through a much stronger care coordination system. So the question is, what have you learned so far in your handling of the commercial population in Blue Cross, Blue Shield, QHP and the UVM self-insured and what means you to believe that the large additional roll out of the commercial market will be successful in that people will see improved quality and improved savings. So you're correct that a lot of our initial work in 2017, 18 and even year to date has been in areas like our complex care program where many more vulnerable Vermonters on Medicaid or with Medicare insurance might see the quickest benefit. But having said that, we've spent significant time since this past summer working with the team at Blue Cross, Blue Shield around advancing some new clinical ideas. Things like thinking differently about primary care engagement and how to both incentivize and open up some access in new ways. Thinking about primary prevention and continuing to expand RISE Vermont and thinking about connection points between those sorts of resources and making sure that there's continuity back through the primary care system. We are talking as well about areas of focus within chronic disease management that may be targeted in different approaches based on unique population needs. So things like innovative uses of telehealth. We're talking about peripheral devices that might be used, say for a patient with asthma to better manage and monitor their compliance with the medications that they're on. Things like how to better address the needs of patients with heart failure. And so I think that there's a lot more work to be done but we see this as an opportunity to get more focused and more specific about populations that are defined around particular chronic conditions or multitudes of chronic conditions. And that is the hope as we are really moving into 2020 and advancing in some of these new areas and programs that you will start to see those things realized in a very focused way. One of the things that's been so frustrating as a board member is to hear complaints about, for example, one care being a for-profit company that we know as a board, that you're constrained by government rules and regulations that don't allow you to do that. And so that brings up the question, people in Vermont have so many questions about one care and what are you going to do to try to get the message out there to the public? It seems like a truly dedicated media campaign has to occur so that people will stop criticizing and try to become more participatory in nature to this transformation to our healthcare system which could yield tremendous benefits to everyone in the state of Vermont. And that's very timely a question for us on given recent events. And we've been talking internally, as you know, we've just been talking about balancing staff and balancing costs. And so we've really focused our time and energy of doing the good work of the delivery system reform and not so much on the media. It has come a time now we do have to really get the message and the word out there. So one of the strategies we've talked about internally is we have a network of participating providers that's over 2000 strong and they have forums and opportunities to be able to tell the story because it's really the story to tell. It's not our story to tell they're the ones doing the real transformation. And I think that in communities, they know the best way to tell that message. And so having that be kind of the ground up sort of story will be really important. And we do have to see if there is some sort of overall media campaign or communication strategy that we would have to employ centrally at one care. I'm just afraid that if you don't start telling your story that there's not going to be a story left to tell. Right. So this is just a suggestion from me to you that I would be reaching out to you can quote me from on addition to all those types of things and go on there with providers and talk to them about what you're saying because the message is not getting out to the public. With that I guess I could, the last few questions, I'll get the answers to on my own. I'm going to turn it over to Mike Fisher. Thank you. Thank you for the presentation. Thank you for your work and the opportunity to ask your question. And I will say, given some of the recent conversation, I think it's important for me to say out loud that I am supportive of the efforts of your organization, the all care model and that you present some details that represent the good work. So thank you for that. Doesn't mean I don't have a few questions. So I have a concern about the population health investments assuming that the full monies from delivery system reform is come through the budget process and with the counting of blueprint and sash and the live monies that can count in some years and not counted in some years and counted now, but with including sort of the best case scenario, your budget has a decrease in population health investments from 4% of your budget to 3% of your budget. And I just want to express a concern about that and give you an opportunity to comment and tell me what's going on. Sure, I can take that. It's a good question. So the population health investments, each program has its own financial model behind and some of them are based on attribution to public health care and others are not and the blueprint programs are one actually that are pretty disconnected from our actual model. They have panels, they receive panel payments and their attribution for the Medicaid population actually goes beyond our attribution. So even if our attribution were to decline in Medicare, that payment is the statewide attribution. The other balance that we're just really trying to manage the budget process is costs on the hospital system as well. And every year evaluating or putting the right investments in the right places and getting the outcomes that we hope to see while also being mindful of the costs that's put on the hospital. So it is a balance and it's complicated because all like I said, all of them have different business models underneath but we're committed to continuing the investments in our provider network and making sure they have the resources they need to take this transformation to the next level. I just had one point. So thinking about the innovation fund as an example, we learned through this process a lot about what it would take for communities to really develop a proposal and be able to implement it. And so we have obligated significant amount of funds in 2019 that actually carried through into 2020 and 2021. As we look at programs that go on for 12 or 24 months. And so when we plan to continue those investments next year, we've tried to do it in a way that feels rational and addresses capacity and maintains focus on those core programs. Thank you. Question about achieving your care coordination, our numbers in your budget. You state that you were attempting to achieve a goal of 15%. Looking at slide 34, well there's a couple of things to take away from slide 34, one was the variation between payers and the other one is the overall number. And it's like kind of a question about both of those things. Sure. So the overall number, I will say that one of the interesting learnings that we've had is that since we ran the focus groups and then got out to town hall meetings around the state to describe the changes coming in 2020 to the payment model, I could put a marker in the months that we did that and see the results in uptick and focus, really senior leaders and organizations making sure that they have aligned resources. And so pick a date that number keeps changing rapidly, which I think is impressive. It starts to beg the question, what's the right target? And I don't think we have an answer to that. We've looked nationally and we've used best practice from a variety of organizations to set that 15% role and we're getting quite close to that for Medicaid and Medicare. As you point out, we are not currently anywhere near that for the commercial program and we didn't necessarily ever intend to be. So when you look at that population, the focus tends to be on the top 3% of risk and you'll see here we're at about 2%. And we continue to have conversations with the leadership team at Blue Cross Blue Shield around some unique nuances in that population. So very rare condition management, things that might not be appropriate for a community-wide model to best support. And so it's in those spaces that we continue to explore what the right evolution of the care model will look like and then how best to allocate resources across the system. I think one of the things that Sarah shared with me during her rounds to meet with the communities is we had set some targets around high and very high risk and sometimes the community said to us, those are the individuals that really are in need of care coordination services. You got to go a little bit deeper than that. And so allowing those clinical decision-making to come into play will be a very important part of the model for us to assess what is that right percentage that would benefit from care coordination? Is it really the top 15% or do we really need to look a layer deeper with that? So that's why a lot of these things are really hard for us to predict right now because healthcare and the way healthcare is delivered is not static. And we learn, we're learning health system and so we're learning along the way. So my next question is very much a nuts and bolts issue. The question I had, I obviously wasn't paying close to the potential. I always understood the distribution of risk to be a clinical decision. And when I looked at the numbers you provided to us and answered one of the questions we asked, I saw an interesting alignment that to Medicaid, Medicare and Blue Cross, you have an alignment of very close to 6% of the categories being in high risk and 10% being, I'm sorry, in very high, 10% being in high, 40% being in medium, so on. And I didn't expect to see that, so we'll look up some description. So that is an approach that we call population segmentation. And there are different models for that around the country, but basically what we did is we looked at conversations with our providers early on, this is back in 2016 issue. We said that while an insurance based model typically focuses on the top two or three or maybe 5% of risk based on cost and utilization of services, we had a provider network that felt like a lot of the opportunity that really existed to have a positive impact on an individual's life was in that next strata of risk. And so we started to look at that from an analytics perspective and we started to say, well, what defines different points where we might move from one segment of the population to the next. So for example, in the early data we looked at, we were looking at Medicaid and we were trying to understand how often when we saw individuals that had complex physical health needs that they also have mental health needs and we were able to see that if we extended our model and we thought about that next 10% of risk that we hit something in the neighborhood of 80% of individuals that could be identified as having more complex needs. And so as a result, we really refined that population segmentation approach and we do have to your point Mike, 6% is the very high risk, the next 10% down is high risk, media risk is 40% and then the lowest quadrant of risk at 44. So my question is more, the 6% of the highest need in Medicaid is bound to be different than the 6% of the highest need in the blue cross qualified health plan. Yes. And that's a different way of slicing it. It looks more like a contractual decision than a clinical decision. It really wasn't. It was something we used the same clinical rumor and we divided up by payer program recognizing that there are unique needs in each program. And what we saw in the early data was that there was plenty of opportunity so that we, as we tried to align around the standard care model and approach to population health, we were really trying to make sure that our provider network was paying attention to that both holistically and then looking at opportunity in broader segments of the population. So we didn't want to overly restrict that. One of the learnings that we've had this year and after the conversations is that in doing that particularly in our Medicaid population, we perhaps underestimate the impact on children because we don't sediment by age in that Medicaid population. And so one of the things we're studying right now is if we break that apart into two populations, a child cohort and an adult, what does that call us clinically about opportunities for intervention? Okay. Last question or questions about the ASO population. I was interested in, Tom, you were saying that a very significant number of the Blue Cross self-funded groups into a scale target qualifying fashion. And I'd love you to talk a little bit more about where's the line in order to achieve a scale target qualifying? And I of course have next to no information about what's being discussed to bring these populations in. So, I think that would be sure. Yeah, good question. So the all-hair model contract determines which ACO programs qualify under that model. And there needs to be provider financial accountability in some way, can be an upside only program but there needs to be some provider incentive in that way and there needs to be quality component to the program. The reason I mentioned that we're transitioning those UVM lives or the building that program to be scale target qualified is that we did an on-ramp year, or we're doing an on-ramp year right now at Blue Cross that incorporates number of those lives but in a non-scale target way. As a way to get some data in, start to learn about that population a little bit more and then we'll be transitioning that into a program that qualifies to those scale targets under the all-hair model and the state's accountability through scale. So, I'm interested in seeing the details and it might be that the negotiations are continuing, it's hard for you to get those details, but. And I would just add to what Tom said and yes, these negotiations are continuing with Blue Cross to shield and so we don't wanna get too in front of that conversation but the other piece for the scale target is make sure that we're reporting on quality measures that we have alignment and overall quality measures that we have a similar parent model that we have for other populations and approaches that we're not limiting benefits in any way, shape, or form that we're applying in enhancements in the same manner across. So those are the type of aspects that we wanna make sure that if we have a scale target eligible program that is meeting all the criteria necessary that the state and federal government has put forth to say now you can say these lies are under a value-based system. Last question on that same area. You know, all of us are interested in transparency and I'm wondering whether those employers let alone the employees know that there's discussion about them being added to being attributed to one parent. It's our understanding that Blue Cross Blue Shield is having those discussions with employer groups as part of their relationship. So really understand that an employer who's working with Blue Cross Blue Shield as a TPA has the ability to make those decisions. Our contracting relationship is directly with Blue Cross to say we will offer a scale target eligible program and for those who are tribute, you know that would be what our contractual relationship is. So we're directly working with Blue Cross Blue Shield and Blue Cross Blue Shield is working directly with employers that are a part of their TPA work. I'm getting the impression offered. I know this is awkward because I'm speaking about an entity that's on you, but I'm getting the impression that this is something that's being offered to those employers that choose to join. That's our understanding that that's being offered to them. Thank you very much. Thank you Mike. This time we're gonna open it up to the public comments or questions. We have a back. Susan. Good afternoon. So Mr. Chair, this is actually a question I made for you. I need your name please. Susan Aranoff and the senior policy planner and analyst for the Vermont Developmental Disabilities Council. People in Vermont with disabilities are more than twice as likely to get their healthcare insurance through a public program like Medicaid or Medicare. That's more than double people without disabilities. That's from a recent department of health study on the health of Vermonters with disabilities, which would be a great thing for this board to hear about. I thought it was really interesting today that part of this was built as a hearing on the 2018 results that was added to the captioning for today's meeting sometime between last Friday and today. For months this had been built and noticed as a hearing on the one care budget. But at some point it was added to be a hearing on the one care budget and 2018 results. So we did get a couple, three, four slides out of 2018 results. One care is required through the regulations and the budget, well really through the budget guidance to submit financial performance results, quality performance results from all of their programs as part of the budget process. But as of right now, and I guess our legislators are left in the room, as of right now there is no legal requirement that the board itself have a hearing on the financial performance results, financial quality performance results of the entity you regulate of the project you sponsor. I think the pilot is still in effect. So I implore you again, this is my third time, publicly, to please have a hearing on the 2018 financial quality results. We hear that they got 100 in Medicare, but that's because they got full credit for reporting and we know last year their Medicare quality results had slipped 10%. We understand they got 86% on their Medicaid results, but we know that that went down last year on seven of the 10 measures, maybe just a little, but we need to understand why. We know they lost money this year in Medicaid and are expected to lose more next year, or eight million more, and maybe that's misinformation. Maybe we need a hearing to get the correct information, but that's the information that I've leaned in and as you know, I follow this pretty closely. So if you could please, sometime as you're considering your budget as an independent regulator, have a hearing with witnesses and earners as one care, someone from Medicaid to talk about quality and performance, someone from Blue Cross, someone maybe from Medicare to talk about how they're actually performing so that you guys, when you're looking at the budget, can evaluate all of this public money, these millions and millions and millions, what is the return on the investment? Every other agency and department and state government that spends a dime of public money is held really carefully to account for something called the result, results-based accountability. Asking a public-based question, is anyone better off? If so, how would we know? I don't hear the regulators asking those same questions in a rigorous, or not even rigorous, a basic evaluative function. So please, before you vote on the budget, maybe have a hearing, a real hearing, on the 2018 performance result. Thank you, Susan. Other members of the public? Yes, Walter. Walter Carpenter, healthcare activist with remote health for all, Montpelier. I, Kevin Mullen, hit it right on the target with OneCare.  And the real problem is, is that no one really cares about value-based or all-pair, because when you hit with a $6,000 deductible, you're thrown off your Medicare because you make $10 over it. This is what Vermonters encounter every day. In fact, I'm encountering it too, when I just had a scary diagnosis that they thought I had cancer. And I'm looking at, okay, if I get thrown off to help them, how am I going to take care of that? Value-based, all-pair, there's nothing for that. The problem is access. Vermonters also look at Blue Cross, Blue Shield, you know, hitting us up for 15%, MVP would send the 12%, UBMMC hitting us up, CEOs getting two and a half million per year. That's what they see. Value-based payments isn't going to do a bloody thing to stop that. The problem is access. The problem is the system is always going to be geared to extract as much money as it can and not lower costs. And I don't, I'm still, I'm still 50-50 on one care. I haven't made my mind yet on it, but that's what Vermonters see. They don't see value-based doing anything at all for them because the problem is access to insurance issues, is the claim denials, all of that. So you were right when you said that. I actually think there are stories where it is really working for Vermonters. Those are some of the stories that we've heard when we were in St. Albans. People who were diagnosed as pre-diabetic are really doing some amazing things. And I just don't think that the information is getting out there. I think it's- But how is an old payer, this value-based, actually gonna help a Vermont with a $6,000 deductible on an insurance plan through employer sponsor? And it won't. That's the issue. Other members of the public. So I don't see any more nears. So I did notice that there were a couple of times that you were promised to get us additional information. For example, on the position costs of the CFO, et cetera. And I noticed that there were several questions for many board members about the $13.1 million in TAP4, page 28. You did an excellent job in your presentation in breaking that down. But the question on what might be cut if you don't receive that funding, I think the answer was pretty vague. And I'm a little bit worried that if you leave that answer the way you've left it, that you're likely to get a condition on your budget that may not be in the best interests of everyone. Because we'll be coming from this board rather than a reasoned approach thought out on providers, members of one pair and others. And so I would ask you to go back to the drive table and try to put something to us about how you will approach that. You won't know the answer to that question until probably May. And that makes it very difficult. I was gonna say these would be discussions that we're bringing to our board in November now that we understand from the Agency of Human Services that this will be part of the AA process and it seems like in the most recent letter to the healthcare reform oversight committee that that might even be delayed a little bit further so that creates some more urgency for us to make those decisions in November. With that, I want to thank you. We've learned a lot today and hopefully you don't take away from it by our questions that we're not probably the efforts that you're making on behalf of people in Vermont. This is very hard work and I know that at the end of the day it can be very stressful but the good thing is that you can look yourself in the mirror and know that you're doing good things for others in the state of Vermont. So thank you for that work and we look forward to getting the additional information. Thank you. Thank you. There's a new business to come here for the board. Seeing none as our goal, this is for the board. Seeing none as our motion to adjourn. It's been moved in seconds to adjourn. All those in favor, simplified by saying aye. Any opposed? Thank you.


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