Good afternoon and welcome to the Green Mountain Care Board. My name is Kevin Mullin, Chair of the Board, and we're about to get started. The first item on the agenda will be the Executive Director's Report, Susan Barrett. Thank you, Mr. Chair. Just wanted to let folks know that in regard to our schedule for next year, next week, we do have a board meeting as a TBD. So I would just recommend just checking our website in order to see what is on our agenda for next week, or if we do not have a meeting that is really to be determined. And our press release and our board schedule for January will be out in the next week or so. And just wanted to wish everyone happy holidays. Thank you, Susan. The next item on the agenda are the minutes of 12-16 and 12-18. Is there a motion? So moved. Second. It's been moved and seconded to approve the minutes of Wednesday, 12-16 and Friday, 12-18 without any additions, deletions or corrections. Is there any discussion? Hearing none, all those in favor signify by saying aye. Aye. Aye. Those opposed signify by saying no. Motion carries. The next item on the agenda is a discussion of the Medicare benchmark proposal. And I'm gonna turn it over to Sarah Lindbergh. Sarah. Gosh, it's hard to find your mute button. Sometimes, good morning. You technology people. I know right, can't trust us. So good morning. Thank you for taking time to consider a vote on the 2021 Medicare benchmark. There was no public comment received in the public comment period. So the proposal is for performance year 2021 to use a retrospective trend factor for the benchmarks for the ACO and that we will include advanced savings in the amount that is advised in the budget process. I think it's about 8.6 million but they have all the details on that. So that's just a mechanism by which to fund those savings to help fund some programs in the state. So any questions before we consider a vote? Questions from the board. If not, we may just wanna open it up to public comment just in case any member of the public has comment at this time. We haven't received any, but does anyone from the public wish to comment on the Medicare benchmark proposal before we take a vote? Hearing none, is there a board member who's prepared to make a motion? I see you shaking your head, Robin. I am. So I move that we propose to the center on Medicare and Medicaid innovation that for the 2021 performance year, the Vermont Next Generation ACO program use a retrospective trend factors, reflecting the observed changes in actual per beneficiary expenditures between 2021 and 2020 for the ESRD and non-ESRD Vermont Medicare beneficiaries eligible for attribution to the ACO and an advanced shared savings component in the amount determined in the budget process. Is there a second? Second. And Tom, could you repeat the motion? I just feel like I'm not. It's good. It's so good. At every meeting, I'm so thankful for Robin. All motions are hard to craft. Is there any discussion? Hearing none, all those in favor of the proposal signify by saying aye. Aye. Aye. All those opposed signify by saying nay. Let the record show that it was a four to nothing vote and it was unanimous, but we have one member absent today. Thank you for your time. Thank you, Sarah. Okay, now I'm going to turn it over to Elena Barabee and Marissa Melamed for continuing discussion on the ACO budget for the coming year. And Elena and Marissa, whenever you're ready. Okay, thank you, Chair Mullen. I will be sharing my screen. Let me know when you can see that. We can see it. Great. So Elena Barabee, Director of Health System Policy and Marissa Melamed. We are here to hopefully, also a potential vote on the ACO budget. So today we'll talk about the process to date. Briefly follow up the 12-18 presentation. Outline some public comment that were submitted since the 12-9 conversation and then review staff recommendations and budget order conditions. Next steps, again, public comment and then a potential board vote. So how did we get here? You've seen the staff recommendations over the last couple of weeks. We incorporated relevant FY20 budget order conditions and considered the new recommendations. We incorporated board feedback, public comment to arrive at today's budget order conditions that we will be presenting to you subsequently. So those recommendations that did not end up in the subsequent slides could have been added either to the reporting manual that we discussed or are going to be part of the, our recommendations for FY20-22 budget order guidance. So, we can follow up on that at a later date, but all the recommendations we kind of carried forward in one of these mechanisms. Today we'll focus on the FY21 budget order conditions. So in follow up to the discussions on the 18th, one care sent a letter on the 21st, clarifying information on their proposed plan related to the blueprint funds flow and the desired Medicare trend rate for the advanced shared savings component of the 2021 benchmark. We also received a public comment which we note later from AHF that we asked for their opinion on this matter. And we took forward both of those considerations and incorporated them into the proposal today as well as some of the board conversation that we've had to date on this matter. In terms of public comment received, we received five additional public comment, one of those in the AHS comments on the blueprint for health. Those are posted to our website. And now we can go briefly through each of the budget order conditions. There are 17 in total, so I won't read them here because they will be discussed in each subsequent slide, but the first condition talks about what I referred to earlier about moving some of the reporting requirements to a reporting manual. That way we can kind of standardize and think about these things as an ongoing kind of monitoring program rather than tied to specific budget order. This will allow us to foster continuous improvement in this area, but it would cover things such as network development, attribution, payer programs, their financials, administrative expenses, risk population health. So any kind of reporting requirement could be specified and included in this guide going forward. The second budget order condition is related to scale target ACO initiatives. So this is an updated condition for FY 21. So to the greatest extent possible, OneCare must design payer programs to qualify a scale target ACO initiatives. If they don't, they have to provide justification to the Green Mountain Care Board for why it wouldn't be a scale target qualifying program. So this is pretty much holding over from a prior year, just a couple of tweaks, but substantively it's the same requirement. The third budget order condition is an updated condition from 21 that discusses the trend rates for each of the payer programs. As Sarah mentioned, the Medicare benchmark, the Vermont Medicare ACO initiative, the trend factors, we would expect that the budget would reflect trend factors proposed by the Board and approved by CMS. So that's through the benchmark process. The Medicaid Next Generation ACO program, those factors should be consistent with the recommendations through Board's Medicaid advisory rate case. And then on the commercial programs, the 21 benchmark trend rates for commercial programs must be consistent with ACO attributed population and the GMCB approved rate filings. So these are all generally consistent. I think the difference here is that we don't include some of the factors to allow for kind of the pandemic associated process adjustments, but we don't have any concerns about hitting the all payer model kind of total cost of care targets, but we do want to make sure that the ACO's budget is reflective of these other processes going forward. We also kept some of the language around actuarial certification and this pointing to the all payer model kind of targets and growth. So just for consistency's sake, we wanna make sure that that continues to live in the budget order. Condition number four is an updated condition from FY21. This states that the maximum risk amount that one care may assume is as follows. So there were reductions to the risk corridors across many of their programs due to the pandemic this year to allow continued participation despite some of the financial constraints experienced by providers. So this memorializes those reductions and risks in this condition. The risk model is an updated condition for FY21 but has some new elements. So one care must implement the risk model that is described in its budget proposal and must request and receive approval from the board prior to making material adjustments. So they must continue to submit copies to the board of the contracts that bind each of the risk-bearing hospitals to one care's risk sharing policy. They must notify and seek approval from the board as early as possible for any of the proposed changes. However, this year, I mean, I think there's still a little bit of uncertainty about how the risk model methodologies will work and then specifically as relates to the 10% performance incentive pool or any other market factor adjustments or potential adjustments to shared savings or losses. So we would request those additional details by the March 31st deadline, which is consistent with their submission of the revised budget. So all of those dates are correlated, but I think we can talk about what the right timeline is based on kind of how the contracting process and other related processes may unfold. And then, if we need to, we can have them come in and discuss the details of the risk model and kind of those final components on April 15th. The revised budget, this condition was updated for 21. I believe many of the same kind of, the content is still pretty much the same, but there may be additional asks depending on kind of where we land in this budget order for what we ask them to come provide updates on. So as always, any other information that board deans relevant can be requested for this presentation in April. Budget order condition number seven is related to the revised budget presentation, but we request that all supporting materials are provided by March 31st. This allows staff time to review the materials prior to the presentation. So we can assist in formulating any questions or analysis that may be necessary. And we've detailed here many of the same kind of deliverables associated with the previous condition and then attached a couple additional requirements related to recommendations. So I'll just point those out. We'd like the source of funds for the population health management programs for 2021, quantification of the value-based incentive fund. So we understand there's some differences in how that's being operationalized this year. So I think we need some additional information on how much value-based, how much value-based, how many value-based dollars are still going through the system controlling for the timing of when those funds would be doled out. And then one care is most recent strategic plan. If that's not compared by March 31st, we'll work with one care to figure out what the right time line is. We understand this is something they're working on in the near future. And then any other information the board deans relevant. All right, administrative expenses and then I'll turn it over to Marissa. So on administrative expenses, we propose two options so far. I think we added this third option really because we weren't, we didn't feel satisfied with the first two options. So what we did first is kind of signal that delivery system reform funding in the blueprint self-management contract are not certain revenue sources or expenditures. So if that, if does that do not materialize, we would expect a revised budget submission that can be consistent with the March 31st deadline. In addition to that, I think it would be helpful to get some benchmark information on salaries and benefits as we do in many of our other regulatory processes. And as you know, we've struggled with how to think about the magnitude of administrative expenses at OneCare this year. And I believe it was disappointing to see a budget that reflected the sentiment that the pandemic was not yet over even though we know that there's so many ongoing kind of concerns around the pandemic. We met with state legislators and the outlook is not looking good. There's no federal relief coming at the state level. People are hurting and we really need mission-based people to be leading our healthcare reform efforts. Moving away for fee-for-service and towards value-based cares and not to recognizing the need to continue moving away from seeing healthcare as a business and embracing it as a public good. So one that needs to be delivered at high quality and efficiently. So in the spirit of value-based care and ensuring that there's accountability across the system, we're proposing option three that would tie executive compensation to ACOY performance on financing quality. So that is new, but we believe consistent with many of the recommendations provided by AHS as well as the amount of care board staff and believe that this would bolster our progress in moving forward. So I'll turn it over to Marissa now. Good afternoon and thank you, Elena. So number nine is regarding ACO reserves. The discussion around reserves this year focused on one cares net assets as of the end of 2019 and 2020. In our December 18th presentation we recommended to include in future budget guidance and the reporting manual requirements for one care to report on any changes to its reserves and justification for any growth or disbursement, including one care Vermont's board approved amount and date of the board approval. For the budget approval we landed here with this condition, which is basically just an update of the condition that was in the FY20 budget which allows well tells one care with use of the reserve that must notify the board within 15 days of the use. Notification must include the reason for drawing down the reserve for any use that's authorized under this condition with a corresponding cash flow analysis and the use of the reserve is limited to additional funding for population health investments, financial backing for risk incurred by participating providers. C is what we added new for this year which is maintaining ACO wide risk on behalf of participating providers. This will allow for more risk sharing options. D, temporary cash flow issues associated with payer revenue delays or other uses approved by the board. You can go to slide 10. Population health management programs. So the condition here is the same as in 2020. This condition acknowledges that contracts and funding sources are not yet finalized for population health management programs. So final funding needs to be submitted with the budget resubmission in the spring including a description of budget revisions and changes to programs including funding shortfalls or changes in scope. We also ask for an analysis to understand which programs can grow with attribution or other factors. We're looking for growth and investment because these programs are a way of redistributing dollars toward clinical community programs that improve health and reduce costly services but we can't force the growth without a plan for scaling up or without demonstrated results. So we also do monitor these programs through reporting from one care on their evaluation of the effectiveness of these programs. This report was a condition last year and will be updated through the reporting manual but as the condition we landed here. And you can move to number 11. 11 is regarding blueprint for health and stash funding. So this is an updated condition for fiscal year 21. A couple of things happened here since December 18th. We recommended adding the Medicare growth trend of 3.5% to the blueprint and stash funding and requiring the payment design be consistent with the medical home and community health team program payment design approved by the agency of human services. This would allow for the additional dollars to be directed to Medicare participating hospital blueprint practices. However, during the December 18th meeting there was discussion around using the maximum Medicare trend factor of 4.35% and specifically trending the stash funding forward at the same rate as the blueprint. So those changes are reflected in the updated proposed budget condition here. Also that's Sarah Lindbergh alluded to in the benchmark presentation. You can go to slide 12 or condition 12. Condition 12, calling here demonstrated value of one care Vermont. We've also referred to this as ROI either way. We did not change this condition. This has been in previous budget orders as presented on December 9th. The Green Mountain Care Board analytics team is working on two studies to help evaluate this condition. Project one is looks at changes to provider outcomes. Answering or looking at the question does one care change provider outcomes? Project two, return on PHM investments. Looking at the question, what is the return on investment of one care's PHM investments? So we expect to collaborate with one care and stakeholders on the inputs of these studies and report progress to the board. Again, this condition which has been in previous orders is looking at over the duration of the APM agreement. So we did not recommend any changes. Condition 13, slide 20 on audited financials. This condition is updated based on staff recommendations discussed on December 9th. The prior budget order required one care to submit audited financials. This year we are asking them to crosswalk the audited financials which are based on GAP principles or generally accepted accounting principles. We're asking them to crosswalk that financial submission to the budget as submitted, which includes the pass-through or what we call accountability dollars. This is needed because it is important for the Green Mountain Care Board to verify that one care Vermont has complied with its budget order for a particular year. And because budgets and actuals are submitted in different format, that's the budget for accountability than the audited financials which are GAP based. So there's no current way for staff to ensure that the audited financials tie back to the budget order. In addition, the audits aren't timely. They come almost 12 months after the end of the year. So we cannot monitor throughout the year and this recommendation would help. Our staff recommendation here as discussed in previous presentation, also includes requirements that we add the GAP based budget requirement to the guidance in future years. Next slide, which is 21 and condition 14, the one care analytic demonstration. So Green Mountain Care Board staff and board members did this for certification back in 2018. We had different staff, different board members at the time, like several of us were including this condition for 2021 as it's time for refresh. This recommendation also aligns with activities that are identified in the AHS implementation improvement plan. Next slide, condition 15 is a new condition for fiscal year 21 looking at the discussion around increasing fixed perspective payments. The board looks at percentage of fixed perspective payments in the ACO and hospital budget process. This is a key metric for understanding where the system is and moving out of the, what's called the foot into canoes scenario of having both fee for service and value based payments and providers working under both systems at the same time. So to move away from revenue generated through volume more payments are needed through fixed perspective payments. The ACO is our vehicle for achieving that transition through partnerships with payers. So we are looking for one care to work with the payers to propose a timeline or a plan for working toward these higher levels of FPP and we monitor that through reporting. The next, and we're almost toward the end condition 16 adjustment of dates. So we do recognize as mentioned before that there's uncertainty around dates in these conditions. This happens every year around contract execution and uncertainties. Also the one care board of manager meeting dates where they approve different things that we then need to review. So we did put dates in here to keep our eye on the ball. They roughly aligned with previous years. However, we know that these dates have to be adjusted. So this condition delegates authority to adjust those dates to the director of health policy that Elena's position. And so that's so that we can work with one care more smoothly to meet the requirements for the budget condition and adjust dates as needed without having one care be out of compliance with their order. Finally, condition 17 further orders. This is a standard condition in previous orders that after notice an opportunity to be heard, the board may make such further orders as are necessary to carry out the purposes of this order and 18 BSA 93 82. Before we move to board questions, discussion and public comment, I'm just going to review the next steps in our process. If you, if the board is ready, you are able to vote on these conditions today, December 23rd. We then work with legal to issue a formal budget order in early 2021. That usually comes out end of January or early February. As discussed, once contracts are executed, we have final attribution. The ACO will submit and present on their revised or adjusted budget in spring, 2021. And then staff will immediately begin working on incorporating recommendations that have been made into our FY 21 reporting manual. And then we get to begin the cycle all over again with our FY 22 budget guidance development. And this happens between January and spring. Of course, the guidance is issued early in the summer and we start the cycle again. So that completes our review of the budget order conditions. Can turn it back over to you, Mr. Chair, for board questions, discussion and public comment. Thank you, Marisa and Elena. I'm going to try to make this as efficient as possible. And before going to board comments or questions, ask for comment from One Care Vermont on the recommendations that they've seen. And I would hope that at that point, when the board does ask questions of staff, they might also be able to ask a question of One Care on specific points. So Vicki, is that okay if I put you on the spot and ask you for your comments? Yeah, absolutely. Thank you, Chair Mullen. Can everybody hear me okay? I'm in a new location. So I'm always unclear whether or not I'm coming through or not. So thank you. We can hear you and see you. All right, awesome. So thank you very much for the opportunity to give some comments and feedback. I think our collective staff have been working very closely over the last couple of weeks as well as with the Agency of Human Services to get closer on the overall budget orders. Because as you all know, many of our contracts are contingent on the budget orders. And so we'd like to get those closed out before our board meets on the 29th.  The first is around the admin. I just wanna remind folks, and I know that we put this in our letter that the budget that we are proposing this year is actually about $3 million less than the one that was proposed and approved last year. And that OneCare has expanded substantially. And as you all know, no one has done this type of reform work in the past. So it's not like we are an extremely mature organization where there's a clear path laid forward. There's a lot of hard work to be able to move this forward. And it's not always simple work. It's very complicated. I'd also like to remind the members of the Green Mountain Care Board that OneCare has made significant cuts in its budget this year as a result of COVID up to about $6 million reduction in our overall budget. So I would say that OneCare has been acting very responsibly and making sure that the financial situation of those who are making the investments in OneCare, i.e. the hospitals, have the support that they need to be able to enter into these value-based contracts while understanding that their finances are stressed during a time of COVID. So I don't think that was fully appreciated or recognized in the staff's comment. So I wanted to make sure to bring that to your attention. Our board has deliberated extensively on OneCare's budget. All the investors, meaning the hospitals that are part of OneCare have helped to develop this budget and they believe that it is what is necessary to help them be successful and to meet all the requirements that we have of our multiple payer contracts. So making significant reductions in that arena would potentially cause disruption in our ability to carry forward the model as intended. I also, that's all I have to say on the administrative budget piece of it. I also wanted to add that we do support an overall trend increase of the 4.35, but only to the hospitals that are participating in bearing the risk in the Medicare program. And I just wanna give some context as to why this is our overall position. I think historically, the way this model has worked is that the ACO participants received a benchmark and then they received a trend rate increase that was equal to the trend rate increase that was being received by the blueprint and the SAASH participants. In 2020 and 2021, ACO participants will not be receiving a 4.35% increase. Therefore, the risk is asymmetrical and it will be borne by those hospitals that are participating. That's why we are only in favor of providing those increases and trends to the hospitals that are bearing the risk. We believe this is a modest incentive to those who are stepping forward to help the state meet their scale targets goals and not unrealistic given the financial situations that they are in right now. And the third thing I just wanted to comment on was in terms of providing a timeline for the fixed payment for commercial, I think that we would be short-sighted if we didn't recognize that the real fixed payment we need is with Medicare, that right now it is essentially a reconciled fee for service and we will not be able to meet our Medicare benchmarks as a state until that gets corrected. So I think that needs to be first and foremost, one of the recommendations that the state and OneCare will be working with the federal government to really get to a true fixed payment because we are not there yet. So that's my only comments and I thank you very much for the opportunity to provide that comment and feedback. And myself, Sarah and Tom are here if you have additional questions as you deliberate on the budget orders. So my apologies up front, Vicki. I was busy writing down your comments on slides eight and 11 and about the administrative expenses and the sash. And because I was so busy writing, I did not follow the third area of concern you had. Yeah, so the third area was more so, not so much a concern, Chair Mullen, but more a recommendation that in order to be able to meet our scale targets goals, we need to focus on actually having a true Medicare fixed payment. Right now it's a reconciled fixed payment, which essentially means it's just fee for service. And if we really want to get to true fixed payments, we have got to start those discussions with CMS and it's my understanding that they're telling us it's going to be an 18 month process. So I really would. But you're really talking about what you're hoping for us to be able to try to foster a negotiation with the Feds to make a change and not specifically about any condition. No, not at all. I just, I don't want us to lose sight that that's very important to our participants to get to that true fixed payment. And if we really want to meet scale, our focus has to be there before it is on commercial because that is a smaller piece of the work and the total cost of care, quite frankly. Well, let's hope we can focus on both. Okay. All right, thank you. So now I'm going to open it up to the board for any comments or questions. And I will go in alphabetical order beginning with the letter P, Tom Pelham. You're on mute, Tom. Yeah, I'm trying to get myself unmuted there. Well, thank you and thank Marissa and Elena and Vicky for the comments. I'll just start off with this FPP issue that Vicky was just discussing. My concern is that we don't have markers that tell us where we have to be when. And I'm kind of hooking on with Mike Smith's Secretary Smith's concept of rebooting and having everybody in the boat pulling in the same direction. And we know today that FPP is a foundational metric in the ACO process. It is the metric that is designed to leverage cost savings and to leverage improvements in population health. And so I don't, and I know it is complicated. I understand that Medicare is a very big piece of that. But I think it's important to kind of lay down some markers as to where we are right now. And I know from documents that I've looked at that the hospitals that are about 13.9% of fixed prospective payments. And it actually reduced it a little bit from 2020 budget to a 2021 budget. And that of the ACO's portfolio, they're about 33% fixed prospective payment. But I don't know what that means in the context of a more perfect world. And clearly we don't live in a perfect world but from a purely academic point of view, I would hope that the ACO can look forward and say inclusive of resolving the Medicare issue. This is where we wanna be five years down the road, four years down the road, at some point down the road. So we know what we're working toward. And right now we're just kind of going along and these numbers appear like I just talked about in terms of the hospitals, FPP and the ACO's PP. But they aren't leading metrics that we can focus upon. And so as we go through a hospital budget review, as we go through rate review, I would think it would be very helpful to have those metrics in mind. I mean, maybe we are hypothetically almost where we wanna be to achieve the leveraging effects of the capitation for through fixed prospective payments or maybe we're miles away from it. And I just think that we need to as is done with many, many budgets to say, here's where we are and here's where we wanna be. And these are the things that we have to address including Medicare, including commercial to get to the critical mass of FPP fixed prospective payments that will generate the kind of savings and the kind of population improvements we hope for and diminish the reliance on fee for service. So it's, and I'm not looking for, I wouldn't be looking for the ACO to be responsible for this, but just to do the analysis that's set as the entity that is the mixed master in terms of converting fee for service to a fixed prospective payments to say, here's where we wanna be as an organization. Here's where we wanna be, here's where we can be if commercial gets addressed a bit and if Medicare gets addressed a bit so that we have a guiding light that we're working for and we know how near it is or how far away it is. Thank you, Tom. I didn't hear a question in there, did I? No, I might, I might not propose an amendment at some point, just to kind of rework the wording on I think it's slide 15 a bit. So my next area, I can make a question out of it, will the ACO help frame the FPP context in terms of where we are now and where we wanna be at some future date? My second area has to do with this benchmark plan which I've raised for a couple of years now. As we know that the QHP population is a key part of the attributed lives in the ACO but the benchmark plan on file at CMS predates the ACO and the all payer model. And if you look at just the amount of premiums that we just went through in terms of rate review for Blue Cross Blue Shield and MVP, they totaled $542 million of expenditure aligned with the plans or the QHP plans that we don't know whether or not those QHP plans are well aligned with our population health goals. I mean, I know one, for example, that isn't new. There is no pre-diabetes treatment program in the benchmark plan or in the Blue Cross Blue Shield MVP plans associated with the benchmark plan. And yet diabetes is one of the largest chronic diseases that we're trying to address. So what I would be looking for and asking of the ACO is they do kind of a clinical review of the benchmark plan as it stands now, the 2013, 2014 benchmark plan and look at what it allows and what benefits get paid relative to supporting population health and make recommendations to Diva who should be the leader on this. But just to say, here we are the ACO, we're out in the field, we have these metrics we're working for and if the payments from Blue Cross Blue Shield and MVP could be rearranged on an actuarial sound basis to be more supportive of our population health goals, that would be a great thing. And I especially think that this is timely in terms of looking at the effort to realign the blueprint with the self-management of programs. I mean, the blueprint does have a pre-diabetes program which it operates on a shoestring that is the preferred best in type kind of CDC program. But that is not a benefit that you can get now if through a bronze plan or a gold plan or a silver plan. So my request would be for the ACO to advise, not demand, not dictate it to advise, spend some time clinically looking at the benchmark plan, looking at say the bronze plan and saying, here's where those plans match up well with what we're trying to do here in Vermont and here's where they don't match up and then let Diva know that here are some opportunities for them to, as Mike Smith says, have us all on the boat rolling in the same direction. So that's my request. My third area is a question is, how much has the new risk model, the kind of systematic risk model with the 10% kind of a reward for achievement kind of changing it from what they used to say with the mini ACOs to a system-wide risk model, how much has that been scrubbed with hospitals? Because I don't think the vase has spoken on this and I just wonder, I mean, the way the slide is written is that we're going to adopt this and then find out about any adjustments we've got to make in the spring. But I could see hospitals not wanting to be kind of responsible for their own improvements and the savings associated with that as opposed to being part of a wide systematic system that is driven essentially by UVM and the network where they are in a pool of sharing responsibility with them. So I would just feel more comfortable with that if I knew what the hospitals have been exposed to with regard to that plan and what their feedback is before it gets kind of too far down the road and we find out it's not really what the local hospitals want. Maybe they do want it and that would be fine with me. I'm not trying to prejudge them. I just want to make sure that they've been heard. So Tom, it looks like Vicki Loner has her hand up and is prepared to answer your question. So Vicki. Yes, thanks for the opportunity and thanks for the questions, a great question. I wanted to say that I personally had conversations with every CEO and CFO that was part of OneCare Vermont's network. We also brought this through our finance committees that has almost every single CFO in the local hospital systems on that committee and it went through our board of managers which on our board of managers sits every hospital CEO in Vermont and they unanimously voted for this change because it will be better for their hospital system. And we also provided them data as a part of this work to show them what it might look like for shared savings and risk opportunities going this approach. And they were the ones also who voted on what the metrics would be for that 10% increase. So that's a long way of saying that they were very involved in developing and approving this approach. Well, thank you for that, Vicki. I know a lot more now than I knew five minutes ago. You're very welcome. Do you have other comments or questions, Tom? No, those are the three areas I'd like to hear from other board members. Super, thank you, Tom. So next it's gonna be Jessica Holmes, Jessica. Hi, thank you so much. First, a couple of comments actually on Vicki's comments. One was I support incentivizing participation in the all payer model and in fact allocating those blueprint trend dollars to the hospitals that are participating in the Medicare ACO initiative for the reasons that Vicki outlined. I just wanna make sure that those dollars extend to the practices that are participating in the ACO Medicare initiative as well, not just hospitals but practices as well. And this distinction was actually made in Secretary Smith's letter to us. So I wanna make sure that that's incorporated. I concur with the comments about having fixed payments for Medicare. It's certainly on the agenda for thinking about the next version of this model. But I also just wanna make sure that we are also continuing to get more fixed payments in the commercial side of things and a one care strategy is really important for that. So I wanna make sure that we're not losing that initiative as well. In terms of the overall conditions, which I think is what we're here to vote on, hopefully or try to vote on today. I wanna say that I support the conditions that are proposed by the staff. And I wanna again thank the staff for thinking through this. I know they've been working really, really hard on coming up with conditions. And as Vicki had mentioned that the ACO is a new organizational. The board is evolving in its effectiveness as a regulator of this new organization. So these iterations on the conditions and how we regulate are really important. And I feel like there's a lot of improvement here. I want to, the one area that I did wanna speak about was on the admin costs. And there were a couple of options there. So I've given this some thought and I wanna say that first of all, I'm very supportive of asking OneCare to resubmit if their delivery system reform dollars or the self-management funding is significantly less than anticipated. It's gonna require a restructuring of that admin budget. I suspect since those are significant dollars coming in. So that I support. I'm also very supportive of increasing our understanding of the benchmarks used to set compensation. I think the board and the public should understand what compensation benchmarks are used, what percentile ranges are targeted when setting compensation. Adding that benchmark condition is consistent with what we do in the hospital budgets and it would improve regulatory alignment. So I agree with that component. I'm also supportive in principle of the notion of tying executive compensation to ACO performance. I think one of the primary functions of the ACO is to tie payment to value. So it makes all the sense in the world for the ACO to do the same with its own executive compensation. Let's reward the leadership team for achieving scale for lowering costs of care for improving quality and remoders can be assured that the ACO's leadership is being paid in a way that's consistent with the goals we have for healthcare reform and aligned actually with the way that we're changing the incentives to hospitals and doctors. It's very much in the spirit of everything that the ACO was trying to do. So it makes sense. I do think though, that if we think it's necessary and appropriate for an ACO's executive compensation to be tied to the organization's financial and quality performance, I think it's probably a standard that we should adopt through the rule for certification. So I think that the benefit of doing this through rulemaking rather than the budget is that the rulemaking process has a notice and a comment procedure that's built into it. And the review of rules looks at whether we have the legal authority to do what we wanna do here. So if the requirement is properly adopted through the rule, it's gonna have the force and effective law. It's also gonna apply to any ACO that seeks to operate in the state. It'll just be a standard that is applied to all ACOs that wanna be certified. I know that the legal team has already been working on our revision to the ACO rule, trying to update some dates and doing some other things. So I propose that we direct them to incorporate this requirement in their updated draft and provide us with an update on it by the end of January. So it's soon. So we're really moving fast on this. The proposed rule change, I think would serve as a notice to the ACO that this is the direction the board is headed and will likely be in effect hopefully by next summer if we can have the rule change implemented over the next few months. And in the meantime, the ACO can use that next six months to develop and implement a really effective pay for performance incentive that does help achieve the goals of healthcare reform. So I guess where I stand in terms of this condition, again, I agree with all the other conditions. Where I stand on this condition is that I would vote to approve option two, which cuts the administrative budget by the expense overstatements that were identified by staff and then direct our legal team to incorporate a new requirement in the ACO certification rule that executive compensation be tied to ACO quality and financial performance and to update us on that by the end of January. So it's sort of a hybrid of two and three, but it's saying let's do the executive comp through certification rule rather than through this budget process. Did you have other comments or questions? No, that's it. Thank you, Jess. Robin. Thank you. I think I'll start with admin because that's where Jess left off. I've been also thinking about the admin options since the staff came out with a couple of different options last week. I like the idea of incorporating the tying of compensation to performance benchmark into the new rule going forward. I think that that is a clearer way to do it and would be clear that it applies to any ACO that may operate in the state. Obviously right now we have one, but who knows? I do like the idea of getting the benchmarks and I am concerned about the DSR and blueprint funds. When Vicki was here last week, it sounded like the blueprint funds were less of a sure thing in the contract negotiations. It will have to wait and see, but together those are 24% of the admin budget, which certainly is a big chunk. So I think probably on which option I would go with Jess's suggestion of option two with pursuing the compensation, moving forward in a clear public fashion through the rule. The other piece I'll just comment on, I do support the staff recommendations as I've been talking about since the October budget hearing. At that time, I did indicate I was not supportive of the level funding of SASH and blueprint, which was described on page 34 of that. Hello. You just cut out for a second. Maybe you can repeat what you just said. Sure. As I had indicated at the budget hearing two months ago, I was not supportive of the original proposal to level fund blueprint in SASH. In the budget submission by the ACO on page 34, there's a description of the level funding. And in appendix 4.3, it's indicated that the Medicare trending did not include a factor for blueprint, which certainly perhaps it was the ACO did not mean to say that they were not trending for the MAPCP amounts, but that's certainly how I interpreted that note that it did not include a factor for blueprint. So I think part of the problem in this area is that the proposal has not been clear. And I still don't actually feel like it's particularly clear what the proposal is when it comes to SASH. When it comes to the blueprint, the statute is clear that the programmatic decision-making as AHS, I'm happy to leave that to them in the ACO to work out what makes sense moving forward. Unfortunately, the blueprint statute is not clear on SASH. So I do think because that funding is coming through our decision-making, that it's up to us to make decisions around that program, at least given the current statutory scheme. With that said, I'll say, if next year we get a clear proposal about how to allocate MAPCP, I'm all ears. I am completely supportive of ensuring that we have alignment across Blueprint, SASH, and the ACO programs. In fact, I think that's necessary. However, the proposal has not been clear and I'm not on the last day gonna change my mind when I've had, there's basically been two months for someone to bring forward a clear proposal. So that's just an explanation I wanted to say in terms of why I'm supportive of the staff condition around Blueprint and SASH and the specificity around SASH. Again, I am happy to hear a new proposal next year as long as it's clear and we understand where the funds are flowing to and from. So I think that's really all I have to say at this point. Thank you, Robin. Elena, could you put up the slide that deals with Blueprint and SASH, please? Yes, one moment, please. So my question is for Vicki and it's pretty clear that there's been a lot of confusion from the budget submission up to this point on exactly what was going to be trended and so on. And I heard you again today talk about wanting that trend to go to only those hospitals that participated in the Medicare program. And so can you just be more clear on what your position is on the SASH funding? Sure, I can. So our position on the SASH is that it would be level funded that the 4.35 inflationary rate would be applied to those communities that are participating in the Medicare program. And so that 4.35 would go to the community health teams. And the reason why I think what has evolved since this pandemic is that it's become very clear that the trend rate for the ACO participants will not be growing at a 4.35. In fact, for 2020 and 2021, we're probably looking at a negative trend rate. So that's why the position is due to this asymmetrical risk that's being created by these new benchmarks to provide the modest incentive to those who are actually bearing the risk in the program. And I think we have said we wanted to hold that money until the end, but understanding the board's concerns that they wanted to get this money out the door to support the blueprint, we can make those quarterly payments out to those that are participating. Is that helpful, Chair Mullen? I'm somewhat, I think what I've heard from my colleagues and it's certainly my position is that as much as possible this board would like to see almost every expenditure tied to benchmarks or performance standards where things are met. And I see in the language here that what the staff has recommended is it would be contingent on the increase in funding being used to enhance programs or to expand access for Medicare beneficiaries. Vicky, do you know if there has been an increase in the number of Medicare beneficiaries that the SASH program will be serving for the coming year? No, they have set panels in our contract. So that's why there's level funding. So they'd have to increase their panel sizes. So given that there's been evaluations that have showed savings from the SASH program, have you created any incentives for them to increase their panels? Is there like a waiting list or? We have not, I mean, we have not seen or we have not been able to simulate the same level of savings that was done, I believe, pre all payer model, it was 2010 to 2016 in the SASH participants. But that's certainly something that we would like to look at. Okay, clearly I think this is an area that we're struggling to find consensus on and one that maybe members of the public might be able to help us on as well. But Elena, could you next go to the, I think it might have been slide eight? Or maybe it was slide 10, condition eight on administrative expenses. Great, you've got it. And here what I heard one of the board members propose is a hybrid model. I would just say that I think that it's been a very tough discussion. One that we've actually had in rate review and other processes before the board to limit growth in administrative costs. I do think that here, one of the bigger problems is what is actually defined as administrative costs. And so I think I am comfortable with what I heard from member homes as a possible solution. I just wanna say though that at a time when many Vermonters are out of work and others are not getting any type of pay increases, I can see the kind of momentum why people would think that people at the director level and above probably could take a year without a pay increase knowing that they did take a pay cut, but also had that reinstated. So the really onerous hit to the compensation has already occurred. And the problem with putting it off till after a rule is that it does nothing for this year's budget. But again, I can live with that. I think that there are other areas though that could be looked at and have been discussed in previous hearings that I really hope the ACO will pursue such as the occupancy costs at the building. I just think it's hard to see in the new world that's been created by this pandemic, the need for the office space that OneCare currently has. And I would hope that there could be creative solutions realizing that there is stickiness to trying to make those changes. I wouldn't be looking for an immediate change, but just from me to everybody listening at OneCare, I think that that's an area where there's no additional value created to any Vermonter as far as better healthcare or lower costs by having what I would call not luxurious, but much more than adequate space for the requirements moving forward. I think we all know that most people will be working in a hybrid model going forward and that we've learned to do so much remote work that probably that size of space is probably no longer needed. So I think there are creative ways that OneCare can find to try to reduce the budget here. And I think that these are things that will take time and will take effort, but I would hope that the underlying framework of any of those decisions is based on which of our expenses create value to the goals that we're trying to achieve and which expenses are just that, just expenses that add no value to the goals or the mission that everyone is on. So, Tom, I think you referred to slide 15 or maybe it was condition 15 and maybe Elena, you could go to that. And I just wanna fully understand what you were proposing there, Tom. So, if you might just be able to state it in what motion you would like to see there and then I might have a comment on it after I think I fully understand where you're headed. Okay, let me just add on to your let the end of your discussion on the administrative expenses. I remember reading in some of the volume this material that we have that the rental contract for the coming year had a 10% kicker in it if the ACO decided to stay in its presence. And we also have hearing that there was an April timeframe of when decisions would be made, if you recall. Do you remember that, Tom? Well, I was just wondering if anybody knew what the value of that 10% was. Tom, it's $45,000. They factored in a 26% increase because it wasn't super clear but that's about the 111,000 increase you see in the budget with a 10% is really 45,000. Yeah, thank you. So regarding slide 15, so I'm not the best drafter of motions but I would at the appropriate time wanna move that the ACO shall advise the Green Mountain Care Board as to the preferred level and critical mass of fixed prospective payments system-wide across hospitals that will achieve significant and meaningful cost reductions and improvements in the population health that may help guide the Green Mountain Care Board with regard to its responsibilities to review and approve hospital budgets and commercial rate increases. So what I'm trying to do is a pretty simplistic thing is like, here's where we are now, where do we wanna be and what pieces need to fall in place for us to get to where we wanna be. I mean, we have a theory out there that the capitation embedded in fixed prospective payments will lead to innovation and reforms and cost savings. That's the theory. Okay, well, let's kind of put pen to paper and say, well, here's where we are in 2020. We know where we are in 2020. We have budgeted for 2021. So how long will it take us to get to that critical mass? But I don't know what that critical mass is. Is it 30%? Is it 50%? I just, you know, I don't know but the ACO as the kind of this, the point of the spear on this issue, I think should know. And at least should be able to put it in an analytical form that we could say, this is the track that we wanna follow and then be able to work through rate review and through the hospital budget process to get us on track as much as possible. Thank you, Tom. Now I understand what you were saying. So I think I haven't heard any feedback on other than those three conditions. And I'll probably, when we get to the point where we're gonna vote, try to take those up one at a time and solve the differences and reach consensus from the board on how to move forward. But before we do that, I do wanna open it up for public comment. And I would start first, if any member of the healthcare advocate staff has any comments or questions. Thank you, Kevin. I don't, we don't have a need to make a public comment at this time. Thank you. Thank you, Mike and happy holidays. Happy holidays to all of you. So I'm gonna open it up to the public for any comments or questions on the ACO budget with the proposed conditions as outlined today from our staff. Does any member of the public wish to offer any comment at this time? So hearing none, I'm gonna take up the three areas that I see some conflicts still remaining on. And I'm gonna start, Tom, with your proposal on slide 15, if you could make that motion. Okay, thank you. I move that the ACO shall advise the Green Mountain Care Board as to the preferred level and critical mass of fixed prospective payments system-wide across hospitals that will achieve significant and meaningful cost reductions and improvements in population health. And that may help guide the Green Mountain Care Board with regard to its responsibilities to review and approve hospital budgets and commercial rate increases. Is there a second? I'll second for purposes of discussion and I may have a friend, what I hope might be a friendly amendment. Sure, let's hear your friendly amendment. All right, Tom, I am reacting to the word shall advise because it rubs me the wrong way given this is a regulatory process. I'm wondering if you would be amenable to changing it to a requirement that they work with all payers to propose the plan that you suggest and that they report that to us. So say that one more time, Robin. So basically, I think you're, so what I was saying is that would you be amenable to having one care work with all payers, not just commercial payers, but also obviously Medicaid in the hospitals and the other regulated entities to try and come up with that kind of a proposal which then could be reported to us and we could have a discussion about it along with obviously AHS. Right, I think that's fine. My intent at the beginning was not to put the ACO in any kind of regulatory hot seat or kind of developing a rule that we all have to live by. It's just taking a staff, a professional staff at where we are now and where we wanna be but that would include all payers. I did not mean this to be limited just to the commercial folks. So I think I accept that as a friendly amendment. Okay, is there discussion on the motion as amended? Manage that's a question. Is it in addition to the condition 15 or is it a substitute for condition 15? I don't think they're mutually exclusive. I think condition 15 would be subsumed within the new requirement because the new requirement is basically looking to do both clear goals and milestones around fixed perspective payments but beyond more than just the commercial payers in a format that we could then look to use that information in this process as well as our other regulatory processes and our thinking moving forward. Is that right, Tom? Yeah, I mean, as I look at the slide, it seems a little tepid to me that the one care will work with commercial payers. And I agree with your suggested amendment that it's broader than that to propose a timeline for working toward higher levels. I'm not looking at a timeline. I want a number. I want them to come and say, well, we've done the best we can. We've talked to everybody. Here are the moving parts. We're at 13.9% in 2021 and we believe that the minimum FPP rate needs to be 37% or 35%. And here's how we can get there and here are the moving parts that have to be moved in order to get there. That's what I'm trying to do. I'm not looking for a timeline. I'm looking for informed assistance and understanding where we are and where we have to be. I guess I just want to make sure. I think what I'd be looking for is a number, a strategy and a timeline. So all three of those components should be in there. But I'm not looking for a timeline to develop a strategy. I'm looking, I agree with you, Jess. I mean, that's breaking it into its appropriate parts. So Jess, what were your three components, Jess? Well, it was a number, a strategy and a timeline. So what's the ideal number across all payers, proportion, and fixed payment? What's the strategy to get there? And what is the timeline, a reasonable timeline for implementation? So maybe we should consider this as a motion to replace condition 15. And Tom and Robin and Jess correct me, but I think what I'm hearing is the motion is to one care must work with all payers to come up with a strategy, number and timeline for meaningful, fixed perspective payments and contract model design with clear goals and milestones. Am I summarizing everybody's statements correctly or what have I missed? I don't think you missed it. I don't think you missed it. I mean, the most important thing to me is where do we have to, where are we now, which I think we know, and where do we have to be in order to get the leveraging effect that our narrative says is out there. And assuming that that takes a critical mass of fixed perspective payments, what is that number? But Jess is right, that's also got to fit into a timeline and a strategy. The number is the most important thing to me, but the timeline and strategy also makes sense. Can I just say one other thing, which is the other way to do this is to pull together a stakeholder group and do it with all the stakeholders, which obviously puts more onerousness on our staff who would have to manage the stakeholder group. So I just wanted to, in the past, that was the mechanism that the board had used to develop this kind of thing. But I think either approach could work. But I just wanted to throw that out there. Well, I mean, I think given this language, the ACA will have to consult with and talk to the stakeholders. Sometimes feel that the stakeholder process is labor-intensive and just goes on and on and on because we got a lot of stakeholders. So I'd rather just keep this within the domain of the ACO, which is at the frontier of fixed perspective payments. So I must admit as the presiding officer, I'm not fully convinced I have the motion correctly. So Robin, do you want to take another crack at it and see if Tom agrees with what the motion is? Of course, I'll try. I think, but I think you did fine, that one care must work with payers to propose a, I'm going to call it a target. I'm going to call it a target. I think a target for fixed perspective payment levels, a strategy for achieving those levels and a related timeline with clear goals, milestones and targets. Thank you, Robin. So Tom, I'm going to assume that was your motion and that Robin has seconded it. Works for me. Works for me. Okay. Is there further discussion on the motion? Before we vote, can we hear from one care about whether this seems like a doable task or perhaps you were about to go there, Mr. Chair? That would make the most sense. Vicki. I was just going to add that, when you're talking about percentages, this hasn't been done before. So to allocate a specific percent is probably an unrealistic expectation. We could certainly look at there's varying levels of risk. There's four levels of risk that you can have in value-based care and increasing those risks over time. But I very much think this has to be part of our strategic planning process to see where we need to be as providers in the value-based care chain and to which type of contracts we really need to be pursuing into the future. So I would just say this might not really sit well if it's not a really thoughtful process in terms of letting our providers know where they need to go and how they're going to get there first. So it seems a little premature before we've had any of our strategic planning, which will not begin until February. And I also just want to add one last thing is one care Vermont doesn't have the ability to negotiate with the feds on the fixed payment. So that would be one area where the state would have to be actively involved in that discussion. So I just didn't want to lose sight of that. Yes, definitely. Okay, further discussion for members of the board. Hearing none, then all those in favor of the motion signify by saying aye. Aye. Those opposed signify by saying nay. Let the record show is unanimous for to nothing vote. The next item to consider is the trend for both the blueprint and sash if we could go to that slide, Elena. So again, I'm somewhat comfortable with this condition because it's tied to enhancing programs or expanding access. And I was wondering, Susan Barrett, if you are still on, if you could confirm that I'm accurate that in the correspondence that we had with sash that they committed to doing more if they receive this. We'll double check that correspondence, but I have had discussions in the past with sash directors, Kim Fitzgerald, that if there were additional funding they would be able to increase capacity and expand. But let me check and see if it's in writing. I'll look at that comment while you're discussing. The one thing for me is I actually am fully supportive of what OneCare has proposed to make this available as an incentive for those that are participating in the Medicare program. And I'm not as wed to the other increases given what we've heard with what the trends will be moving forward, but I also hear strongly from my board members a very passionate plea for the trend for sash as well. So given the language that's in the condition, again, it's just a very low comfort level, but I could also be persuaded that the trend for sash not be there. So I'll open it up for board discussion from other members. I've already said plenty, so I'm not gonna say more. Well, would your motion be then to adopt this condition as is? Yes. I would actually just do it as part of the motion to adopt the conditions in general just because that will be a little bit more streamlined unless I'm obviously in the minority and other folks wanna move to amend it. I have one question, which is I understand the desire by OneCare to incentivize participation in the Medicare ACO initiative on the blueprint side. I don't understand I guess why that incentive could not be carried over to the sash side using the Delta, the trend factor component, the 4.35% increase and allocating that increase to the communities that have chosen to participate in the ACO initiative. So Vicki, would you like to answer that? Sure, thank you. I think it's a matter of the fact that the ACO participants are not receiving that 4.35% increase in their overall trend. So that's factor one, that's very different from last year. So this additional funding will have to be borne by those that are participating in providing risk in the program, which is the hospitals. So you're asking the hospitals to take on an additional $180, $200,000 of risk. I'd also like to add that this amendment doesn't say for those that are participating in the Medicare program and a large portion of the sash participants are not participating in the Medicare program, nor are the communities. So their services, although are good and help the state overall, they're not helping to drive down completely the total cost of care that is being borne by those who are taking risk in the program. You're on mute. Still can't hear you, Jess. Oh, sorry, I muted myself by accident twice. Do you have dated or could you give me a little more detail on your comment that the majority or most of the sash recipients are in communities that are not participating in the ACO Medicare initiative? Yeah, so if you look at the hospital service areas that are participating, I think it's six or seven. I'd ask Sarah or Tom to comment on that. And so with the sash funding, it is statewide. So you're asking us to fund those other communities that are not participating in the program. Right, but I guess I would have thought, for example, that Chittenden County would have been a major recipient of sash funding. And that's certainly one of the participants. I wasn't... They are, when we've crosswalked, those that are participating and the ACO versus not, I can get you some data. It would be older. It's not as substantial as you might think. Okay, thank you. Other board members? Chair Mullin, this is Susan. I just sent the public comment to you, but I can also just answer your question. Kim Fitzgerald did have a public comment and she said if the inflation was not applied to sash that they would have to cut services, just to clarify. And that is posted on our website. So I'm not hearing anyone that seems to have a desire to change this condition. So I'll just give it one last pause to see if any board member has a desire to make any change to this condition. If not, we'll move on. So hearing none. The other, what I would call area of conflict is on the administrative costs. And if you could go to that slide, Elena. And Jess, I think it was clear that you had a motion that you wanted to make. So I'm going to allow that to occur. Okay, sure. I would approve option two, vote to approve option two, move to approve option two, which would limit one carers administrative expenses not to exceed $15.5 million, but also $15.9 million, sorry. Million dollars, but then also direct our legal team to incorporate a new requirement in the ACO certification rule that ties executive compensation to ACO quality and financial performance and that they would provide us with an update on that proposed change by the end of January. Is there a second? Second. Okay, is there further board discussion? Hearing none. All those in favor of the motion signify by saying aye. Aye. Those opposed signify by saying nay. Let the record show that was a unanimous motion. So at this point, Robin, I do believe that you could make a cumulative motion. Great. I move that we approve one care Vermont's 2021 budget with the staff conditions as outlined in today's presentation with a amended and replaced condition 15 and a amended and replaced condition eight which is inclusive of the motions that were already voted on. Kevin. Yes, Tom. So I don't know where this one goes, but I also have a motion on the benchmark plan. I don't know what slide to associate that with, but it's somewhat related to maybe slide 11, but I would like to make a motion to regarding a clinical review with the benchmark plan relative to our population health goals. Would it make sense to vote on the staff recommendation? And then that could, I guess I'd have to withdraw it because of the, it was moving to approve the whole budget. So why did I do that? I think that Tom's motion could be made afterwards. It could go either way. Whatever the board is most comfortable with. Well, why don't I withdraw my motion and we can address Tom's and then we'll do the final. So Tom, your motion is? My motion is the ACO shall review Vermont's current benchmark plan on file as CMS relative to its clinical alignment with current ACO and all care model population health objectives and advise the Green Mountain Care Board and the Department of Health Care, Vermont Health Access as to realignments that will improve population health by being actuarially sound. Is there a second? I'm assuming nobody's on mute and I'm not hearing a second. If I can just add that, the rate review system this year for the QHP populations was $540 million, almost a half a billion dollars. And if that expenditure is not aligned and it might be, I know in terms of prediabetes, it's not. But if that expenditure is not aligned with what we're trying to do with the ACO and the all payer model, then it doesn't make any sense to me. I mean, to me, this is low hanging fruit and that the expenditures on the QHP plans, which we have also approved, should be well aligned with our healthcare reform goals and they just haven't been visited since 2013, but... So I would just chime in to say, I'm not opposed to the ACO doing the review, but having done a review like this before, it's not cheap and it requires actuarial support. And so the reason why I chose not to second it is because I think there would need to be a cost estimate associated with it and an understanding of where that's coming from in the budget and what it's replacing. So that's my main reason why I didn't want a second at a time. I don't disagree with you that it would be helpful to have them weigh in when AHS moves forward on a new benchmark plan. I think that would be very helpful and certainly they could be more assertive with that if they'd like to be, but I just don't... Last time we had federal exchange funds and it was... I don't remember the exact contractual amount, but it was not cheap. So that I just am not comfortable requiring it without understanding the price tag and where the money's coming from. Yeah, I just want to agree with Robin to me. It feels a bit like an unfunded mandate that I don't know what the cost implications are and it's a big lift potentially. And at this late point in the budget process, I don't feel comfortable imposing that without understanding of what the consequences are to their budget. Well, I can understand that a little bit. I just look at pre-diabetes and if you go to the bronze plan and their treatment for Joe as they advertised for diabetes is 7,600 bucks a year. And then you've got the blueprint out there running these workshops for 1,000 bucks for a number of people in a workshop. And if this were $20 million or $30 million in benefit expenditure, I might agree with you but this is a half a billion bucks. And for that not to be aligned especially for the QH population which by and large is attributed, just makes no sense to me. And I'm hearing some rumblings that Diva might be beginning to look at this anyhow. So it would be better to have this resolution in play than not just to make sure that the whole alignment issue isn't lost. To me, this is, I mean, from a fiscal point of view, from a population health point of view, it just makes common sense. And I appreciate what Robin's saying. Everything does cost money but maybe the ACO, we could accept this and have the ACO come back with a budget estimate or something. I don't know, but... So the chair always hates to second a motion and I'm a little bit reluctant to here without knowing what those costs would be. I did see some hands go up for public comment and even though we don't have a seconded motion in front of us, I would like to hear from those, especially from the healthcare advocate and from OneCare and we could move forward from there. So, Mike Fisher. Thank you, Mr. Chair. I only know enough about this to get myself in trouble but I'll just say out loud that I believe that Diva is indicated that they are interested in applying for a grant to look at the benchmark. And at least they indicated that to us recently around other advocacy. And so maybe some of this could be accomplished with some communication to Diva if they're doing so to include some of this analysis. Thank you, Mike. Vicki? Yes, I was just going to echo what board member Lunge and Holmes said was that although I do understand that this is important work and we're always happy to provide input that part of the AHS implementation improvement plan was for the ACO to focus on its core responsibilities. And this seems like one that should lay within the scope of the agency of human services and not OneCare. Thank you, Vicki. I also saw a hand up raised by, and I'm not sure the full name of this person but it says Steve Guest. So our guest, Steve. Hey, Chairman Mullen, can you hear me? I can, is this Steve Gordon? Yes, it is, sir. So I want to apologize for coming in a little bit late to the Zoom call. I was on a call with VDH on the vaccine program down here in Brattleboro. But I see the slide that was up about sash and the blueprint. And I just want to express my concern that if our goal for OneCare in the state is to expand the number of hospitals as part of OneCare, having kind of unfunded increases in programs like SASH or the blueprint or any other programs is not going to be an incentive for the other hospitals to sign. As you know, we are one of the six that have been participating in all the programs at OneCare. But we're going to find it more and more difficult if we're required to fund other programs without having increases in support from the state. So I just want to express that. I know you kind of, you already covered that as part of your presentations and a vote. But I was a little late to the game, but I wanted to share that with you. Okay, thank you, Steve. Thank you. Another comment on Tom's proposed motion. Kevin, one more thing. I would see it as a friendly proposal if the amendment were, or if the motion were kind of revised a little bit by saying the ACO shall suffice. So Tom, why don't you withdraw the motion you made and offer another one? Okay. So I would like to withdraw the motion I made and substitute it with this. The ACO shall subject to available funding, review Vermont's current benchmark plan on file at CMS relative to its clinical alignment with current ACO and APM population health objectives and advise the Green Mountain Care Board and the Department of Vermont Health Access to realignments that will improve population health while being actuarially sound. Does any board member wish to second the motion? Well, I'm sorry, Tom. It's the holidays, but there is no second here. Not the first time. So with that, Robin, if you could go back to your motion. And again, I would just say that if anybody wants to take another crack at slide 15, not slide 15, dealing with the SASH and Medicare trend, I tend to agree with the comments made by Steve Gordon and have some concerns, but I can read the tea leaves where this is headed. So I guess, Robin, go ahead and make your motion. I move that we approve the ACO's fiscal year 21 budget with the staff conditions as outlined in today's presentation with a revised and replaced condition 15 and a revised and replaced condition eight as voted on today. Is there a second? I'll second. Okay, it's been moved and seconded to approve the conditions as amended today regarding slide 15 and regarding the administrative expenses. Is there any further board discussion? Hearing none and since this really is the approval of the budget, I'm going to open it up to public comment one more time. If anybody from one care, the healthcare advocate or any member of the public wishes to make a comment, please proceed. Mr. Chair. Yes, Susan Aronoff. Yes, this is Susan Aronoff. First of all, happy holidays to everyone. Happy holidays to you as well. And I just want to propose something I would really urge the board to do this. It really varies amongst administrative bodies and different sets of rules. When a body like the Green Mountain Care Board issues responses to the public comments that they've received. And the Green Mountain Care Board to date has received a lot of public comment on this year's budget. Specifically, Julie Wasserman's public comment, which was referenced in Patrick Blood's commentary makes a lot of really valid points. And so this isn't really a comment on your vote that you're about to have or on the merits of funding Sasha Blueprint, but the overall value of this whole endeavor to the citizens of Vermont. And I think that it could enhance the credibility or the perception of the Green Mountain Care Board if the board itself took the comments of people like Julie Wasserman or myself when I submit mine or others, seriously enough and respectfully enough to respond to the comments that have been received. And so I'm not, I don't want to put you on the spot now, but I just think it's something Mr. Chair that you and the other board members and your staff might want to consider doing. And sometimes I've seen regulatory bodies catalog the comment received and have some general comments. Sometimes I've seen them go point by point. I just think that there's a difference between not commenting at all. It sends a message, I think, to really just to not comment at all on serious public comment that's received and to go line by line and comment on everything. So I would just encourage you after the vote and after your staff get some well-deserved rest and holiday time to think about responding to some comments because you yourself, Mr. Chair, last year you said, one Carey, you got to tell a better story. And so now they're on VPR in the morning advertising and it seems kind of odd to me, but I don't really think Vermonters had any better sense now than they did a year ago of what One Carey is, how it impacts them for better or worse or anything like that.  And we don't get to hear very much from the Green Mountain Care Board as the Green Mountain Care Board about these very weighty issues. So I would just like to invite, encourage, request some response from the board to the public comment that's been received on the One Care budget and on the Green Mountain Care Board's oversight of this vast enterprise. So thank you and have yourself a very good holiday. Thank you, Susan, you as well. Any other member of the public who wishes to comment? Hearing none, is there any further discussion from the board on the motion? Hearing none, all those in favor signify it by saying aye. Aye. Those opposed signify by saying nay. Nay. Mike Barber, if you could call the roll since it wasn't unanimous. Member Holmes. Yes. Member Lunge. Yes. Member Pillum. No. Mr. Chair. Yes. So let the record know that the budget with the conditions has been approved on a three to one vote by the Green Mountain Care Board. Elena, Marisa and the other members of staff who have worked so diligently on this. I know because we've had the after-dinner conversations how hard you have been working. And I just wanna say that every member of this board is very grateful for the amount and the effort of work that you put into this. And quite frankly, we couldn't do this without you. And so thank you. And I'm actually surprised that we were actually able to vote today because I felt in my gut that it might be next week. And so it's probably best for everyone to move forward on trying to do everything that's necessary to make this program work for Vermonters. And to really hold everybody's feet to the fire on making sure that the goals that this program is trying to achieve are achieved so that we can improve access to care. We can really try to create a better life experience for Vermonters through better help and try to keep people from getting to full-blown chronic illnesses. And so with that, is there any old business to come before the board? Hearing none, is there any new business to come before the board? Hearing none, is there a motion to adjourn? Simon? Second. It's been moved and seconded to adjourn. All those in favor signify by saying aye. Aye. Aye. Those opposed signify by saying nay. And I'll just say that I had created a tradition of wearing my Snoopy Christmas hat and playing music. Because of the seriousness of today's votes, I opted not to do that again. I didn't want anybody to think that I was not taking today seriously. But I do want to wish everyone a very joyous holiday season. And I know it's going to be a different holiday season than everybody is used to. But thank God through technology, we can still have these visual calls with our friends. And I've heard very, very positive comments and feedback back from a number of hospitals in the state of Vermont that talked about how the morale of the healthcare workers had been trying and they were troopers, but there was definitely fatigue being weighed in. But once they started administering the vaccinations, in fact, one hospital CEO said it was almost like the faces were faces that you would see at a party smiling and cheerful. And so it's going to take time, but we are on the road to getting back to whatever that new normal is and just reach out through the phone if you can to anybody that you're concerned with over these holiday periods, because we know that not everyone has the family or friend infrastructure to keep an eye on them. And we also know that one of the outcomes of this pandemic is going to be increased strains on mental health. And so just keep everybody in mind if you have a neighbor that is living alone or struggling with some type of health issue, maybe put a plate of cookies on their front door and ring the bell and leave. But just with that, happy holidays and thank you everyone for the work that's been done today.


You cannot talk about climate action, climate change without putting at the center indigenous peoples as right and knowledge holders that can provide value solutions. There are more than 476 million indigenous peoples living in more than 90 countries in several socio-cultural regions. What is important about the indigenous peoples is that they live in the most pre-steined ecosystems in the world. They can protect up to 80% of the remaining biodiversity in the planet. They have not contributed to climate change, but they are the front lines offering climate change so they don't understand that they are not allowed participation in the real discussions. They are not sitting at the decision tables with the countries to talk about policies and to talk about climate action. The moment these indigenous peoples' food systems disappear, the moment that the spoken language is more than 4,000 by indigenous peoples disappear, there will be a deterioration of biodiversity and on the environment and ecosystems and these connections often are not well understood by technicians and practitioners unfortunately. COP28 is yet another opportunity to increase the work that FAO is doing with indigenous peoples. We have a coalition on indigenous peoples' food systems and we discuss how to advance the agenda of indigenous peoples' food systems in the context of climate change. This is very relevant for the next COP.


Hello and welcome to this presentation. My name is Badr Dean and in this video we will learn how to cache the bitmaps stored in the SD card. In the first part we saw how to set up the SDMMC peripheral and add FATFS file system to the SDM32F746 3rdGFX template. In this second part we'll see how to cache the bitmaps stored in the SD card into the SDR. I have my SDM32Q by DE launcher asking me to select a new workspace. I will use a new workspace for this project and click launch. Here I have my SDM32Q by DE project open. I'll close the information center and expand the project here. I will start by setting up the bitmap cache which consists of a pointer to a buffer and the size of the buffer. I will expand project, then application, user and then touch GFX and then target. The bitmap cache setup is done in touch GFX, hold dot cpp, double click on the file. The initialize method we will set up the bitmap cache. By default the template uses 3 frame buffers of 261 kilobytes each. The total size of the frame buffer is BF400. Here we set up the start address of the cache right after the 3 frame buffers. The total size of the cache is 8 MB which is the size of the SDR. For the user manual of the SDM32F746 discovery board we have an SDR of 128 MB but only 64 MB is accessible, so 8 MB. So the size is 8 MB minus the size of the 3 frame buffers which gives us 7.4 MB or 7400C00. Then I will remove the default bitmap cache configuration and last but not least we set up the cache based on the start address and the size defined above. Here we cache up to 128 dynamic bitmaps. Next we will go to GUI mainview dot cpp and here we tell touch GFX framework which bitmaps to cache. We have 2 cache strategies, either we cache all the bitmaps or we cache specific bitmaps per ID. For example I can cache the background image on the setup screen and I can cache the image that I have on the main screen image 00 or I can cache all the bitmaps using cache all. So I can do bitmaps cache all. And of course in this case I need to remove these 2 lines. If we need to cache all the bitmaps of course the size of the cache must be large enough to contain all the bitmap data. Then of course we need to clear the cache and the tear down method. So here in the setup screen method we cache all the bitmaps and then in the tear down screen we clear all the cache. Now I will modify the linker script in a way to add a new virtual memory area SD card that starts from 0xA00000 with the length of 7MB. So I go to the linker script here and in the memory section I add a new memory area that is virtual that starts from the address A00000 and the length of 7MB. And then here I tell the linker to place the external flash section which contains all the bitmaps into the SD card virtual memory. And then I'll add the keyword noload here to tell Q by D not to load the binary to that section. If we look into that JFX designer and then images tab we see that the background image and image 00 are both placed in the external flash section. We'll go back here and what we did is we placed the external flash section in the SD card. I'll keep the font and the text flash section and the quote spy. When you cache a bitmap, TADGFX copies the pixels from the original location to the bitmap cache using the block copy function in TADGFX.cpp. In our case the bitmaps are stored in the SD card which is not a memory map memory. Then we need to add the FATFS red operation from the SD card. If the address is within the SD card virtual memory region then we use FATFS file to read the data. We calculate the offset within the SD card virtual memory. We place the file pointer to that offset then we read the number of bytes from the SD file to the destination address which is an SDM address. Else meaning if the address is not within the SD card virtual memory region then we use the default implementation. Of course before I can read it from the SD card I need to mount the file system and then open the file and I want to do that only once. So I'll do FATFS, if FATFS in it is 0 then mount the file system to SDFATFS and then open the file SD file and then set the variable to 1 to make sure I mount and open the file only once. Then I need to define these variables. So I already have the FATFS files or FATFS variables defined here. For example FATFS.c I see the SD path is defined here, the SDFATFS file system object is defined here, the SD file is defined here. So what I need to do is to define them here as extra and then I need to include the header file for the FATFS. And I still need to define FATFS in it variable and the byte thread variable. And here I have SD path copied twice, I need to remove it. Now I'm ready to build the project, select the project and click on build. We see here the build finished successfully.


Hey there friends, thanks for checking in. Today we're looking at a Milzbeck 1911. This would be considered a Bear Bones 1911, made by Springfield Armory. On many accounts that I have researched, they say that the Springfield Milzbeck 1911 is the closest to the original. So we're gonna take a look at that today, check it out, many of the features. The basic features have remained the same throughout the years, but this does not have all the modern enhancements, the forward serrations and night sights. I'm seeing even red dots on 1911. Browning is rolling in his grave. But you know what? The purists and the traditionalists say, give me this. I'll take this 10 times out of 10 because I don't want all that other stuff. And that's what we're looking at. Let's start with the mag. Seven round mags, all right? Many of the modern 1911s have eight rounds, even higher. You know, I've got a 10 round mag, single stack. This is a seven round mag. And we look at that grip. It's a wood grip, diamond checkering right there. And the mainspring housing is arched. You seldom see that on a modern 1911 and arched mainspring housing. There, the standard now is flat. You know, flat mainspring housing. And then the front strap here has no checkering at all. Okay, rather smooth. If we move up to the thumb safety, you can see that it's rather small. It's where the modern ones are a little bit larger, a little more real estate there. But it'll work just fine. You can see my thumb did slip off on that one. And a spurred hammer, check that out. And we do have an unloaded firearm here. The single action trigger is, I think it's nice. You know, I measure it just under five pounds, like four and three quarters pounds. It's a single action trigger. That's what originally drew me to the 1911 and has kept me here for years is that single action trigger pull. It is so nice. I just love it. Just under five pounds. You'll see many of the modern 1911s, you know, three, three and a half, four pounds. Maybe a little bit more. But I don't have a problem with that. It's a solid piece, no skeletonized trigger there. And the finish is pretty well parkerized. See that? No flare, no gloss look to it. No sericote, that's for sure. And then we have fixed sights. This has three dot.  But I did get some good range time with it. Let's go ahead and roll through some of the footage. We'll take a look at the internals and see what you think of a mill spec. A bare bones 1911 that many people will choose. They'll choose this over all those fancy ones. So let's check out the shooting. 230 grain hollow points, real tight rear serrations there. When I disassembled, you may have noticed the GI style guide rod. Many 1911s still have that. All right, and one of the ways you'll know is that you won't see a full length guide rod. Okay, it's covered by that spring cap right there. But also the beaver tail, it's really not extended. You see a lot of the 1911s now, the beaver tail's extended out the hair. Nice, nice big curve angled, you know, not so much here. But the components, the shooting impression for the most part is essentially the same with the mill spec. It just doesn't have all those enhancements that people love and it's an original or close to an original that other people very much love. It all depends on where you stand. I happen to love many of the modern features.  But this is the original and the purists will choose this 10 times out of 10. And I think it's pretty cool. And I definitely enjoyed shooting it at the range. If you like videos like this, please subscribe. And sure, I always appreciate thumbs up button. Thanks for watching and you guys be safe.