All to order the Green Mountain Care Boards meeting of November 8th. Today we have the one care Vermont fiscal year 24 budget hearing. And we'll start with a staff introduction from Michelle Sawyer. Then we'll hear from the 1 care team and then we'll have board member staff member questions board member questions. HCA and public comment. So with that, I'll turn it over to Michelle Sawyer, our health policy project director. I'm sorry, are we on the record? Oh, sorry. Yeah. Okay, we are now on the record. Thank you. I should be better at that. And I'm and I'll call it order the Green Mountain Care Boards hearing of November 8th 2023 for the 1 care Vermont fiscal year 24 budget presentation. And I'll turn it over to Michelle Sawyer for a staff introduction. Thank you, chair Foster. I'm here today to introduce 1 care Vermont. As they are here to present their FY 24 budget. The GMCB has been tasked with the oversight of accountable care organizations as it is outlined in 18 VSA 93 82 and rule 5. The board will conduct both certification of ACOs and an annual budget review. 1 care has been certified and the staff verify continued eligibility for certification on an annual basis. The board reviews the ACO budget annually, usually in the fall prior to the start of budget of the budget program year. Pay your contracts and attribution are finalized by the spring of the budget year and then the ACO submits a revised budget. All ACOs operating in Vermont are subject to budget review. The threshold of 10,000 lives defines the scope of review by the board. Review of the ACO budget does occur annually, as I said, and the board monitors ACO activities and performance throughout the year to ensure compliance with requirements of budget approval or conditions. And to ensure the ACO is operating as required by Vermont's all payer model agreements. The standards and requirements by which we review the ACO submissions are set forth in 18 VSA chapter 2, 20 GMCB rule 5 and the all payer ACO model agreement and specifically under rule 5.405, the board considers any benchmarks established under this section of the rule. The benchmarks noted here are the budget targets the board voted to include in the FY 24 budget guidance document, statutory criteria are in the reference slides of the slide deck, which are publicly available on our website. And the ACO shall have the burden of justifying its budget to the board. Here is a timeline for this year's review. The guidance was released in July of 2023. Certification materials were submitted in September. October 2nd was when one care submitted their FY 24 budget today. We are here for one cares budget hearing. There will be a presentation at the end of the month for the 2022 financial settlement and quality performance of the ACO. The staff, the GMCB staff will be doing a budget analysis presentation on December 6. There is a tentative board meeting for the 13th to discuss additional staff recommendations and deliberations and the first date for potential vote on one cares FY 24 budget is scheduled for December 20. Public comment is accepted throughout this entire process. They should it should be submitted by Friday, December 15 to be considered prior to the board deliberation and vote. So here's the agenda for today. We just went through the staff introduction. Next, we'll hear from one care. They will present their budget. There will be staff questions, board questions, questions from the healthcare advocate, public comment, and we do. If there is a need for it, we can go into executive session at the end.  All right. Thank you very much. I'm going to have Mr. McCracken swear in the witnesses for one care. And then I think we allotted 60 to 70 minutes or so on for the one care presentation. If that works for you. So, Mr. McCracken, if you could swear the witnesses. I agree. Thank you, chair foster. Mr. Berman, do you mind confirming who from one care is going to be testifying today? Sorry, I think you're on mute. Sorry about that. From one care myself a Berman interim CEO. Tom Boris CFO. Sarah Barry, COO. Carrie Wolfman, chief medical officer. Great. Sorry, just cut out for me for a minute. If you would all please raise your right hands. I'll swear you in. Do you solemnly swear that the evidence you shall give relative to the cause no under consideration shall be the whole truth and nothing but the truth. So help you God. Yes, I do. I do. Thanks very much. And I will turn the presentation over to you. Thank you. Good morning. My name's a Berman. I use the pronouns he him. I'm proud to serve as the interim CEO and leader for the one care team and the participant network. Thank you for allowing me to address you today. I want to start off by emphasizing something we all know change is hard, especially in healthcare where institutional inertia is strong. All of us are committed to this challenge or wouldn't be engaged together in this work to serve our monitors. The starting point for change is a strong foundation in what is and what isn't working today. A willingness to challenge existing norms and paradigms and a commitment to use our New England grit determination fortitude when the going gets tough. It comes down to our strategic plan when we talk about moving from a coalition of the willing to a coalition of the committed. It comes down to aligned incentives, next level use of data and strong collaboration across the entire healthcare continuum. So how can innovation happen in uncertain times when margins and budgets are strained and the needs of the community only continue to increase. Disrupting the status quo is both the answer and the challenge. The flexibility to cope with constantly evolving programs and conditions while delivering effective care leads to a level of change fatigue. That's why we need to focus on evolutionary change that builds on what works. We've listened to you the budget that we've submitted is designed to sustain and enhance critical programs and continue our progress on lowering healthcare costs and improving population health outcomes. While we work together as a state on what the healthcare system of the future will be. We left no stone unturned and considered nothing sacred. This was truly built from the ground up. Our presentation will focus on key elements of the budget and highlight noteworthy investments and initiatives. These include the population health model. The comprehensive payment reform or CPR program. The mental health screening initiative as well as special funding to support and promote the use of key waivers. This budget helped providers who voluntarily entered to our program deliver the best and most cost effective health care to our monitors by aligning focus around key population health metrics and providing support. Resources and incentives otherwise unavailable apps and the ACO structure by providing these supports and paying for value and better health outcomes rather than individual services. We're moving our health care system toward a higher quality, more affordable and better coordinated model that will keep for monitors healthier. We aren't perfect about six months into this role and working hard to provide a sense of stability and leadership and highly uncertain times while finalizing our goals for the coming year. I come to you open minded and desiring of feedback. This includes both a recognition for what is working and constructive criticism on what isn't. I want to stress that the one care team is developed substantially over the course of the APM and is filled with talented caring and hardworking professionals that share your desire to create a better tomorrow for Vermonters when it comes to health care. They know how the nuts and bolts and nitty gritty details of the PIM models work, how to handle and collect complex measures, how to manage and contract with a large diverse provider network, and how to do all the accounting on the back end. These are not skills that are readily available in the labor market. Take it from someone that used to handle the entire Northeast network team for the largest insurer in the country. It's important to note though, as you've seen in our voluminous filings and submissions, there are a lot of things that are working and you don't just have to take my word for it. Vermont tops four plus to the best health care of the states with the best health care outcomes coming in at number five overall. While all of this certainly isn't solely due to one care, it's a testament to the work we've done together as a state to transform our health system over the past 20 years. The most recent NORC analysis commissioned by CMMI concluded that we successfully drove down costs and hospitalizations over the last four years. They allotted one care's investment in primary care and its work to promote collaboration amongst health care providers. The report specifically cited the importance of a unifying entity like a statewide ACO to achieve these results. Our participating providers are highly satisfied with our approach and site programs like CPR as lifesavers that enable primary care practices to hire additional practitioners and expand care teams to address mental health and substance use disorder. That said, we are the first to recognize that our work is far from done. There's so much more we can and will do to further innovate and evolve the care delivery system and improve the economics of health care for Vermonters. So I present to you a 2024 budget that will allow us to continue to make critical investments to do just that. Despite cost inflation, we've successfully delivered a focused and fiscally conservative budget that's largely consistent with 2023 despite inflationary pressures. It supports primary care, lowers administrative cost, and sets the stage for us to meet or beat financial targets in each of our payer programs. This budget supports value based payment design and important advancements in our essential programs such as the population health management program that increases accountability for quality outcomes, the CPR program that improves the viability of independent primary care practices in our state, and the mental health screening initiative to improve mental health screening rates and follow up. It's intended to continue and build on essential programs to deliver the tools providers need to coordinate with one another. Cutting through red tape to ensure Vermonters are receiving the care they need in the right place at the right time and ultimately lowering costs and improving patient care. Our investment in these programs is data driven and incorporates feedback from this board as well as our providers and what works best for them. Now I'm going to turn it over to Tom Boris who's going to take you through the budget in more detail. All right. Thank you. Hey, good morning everybody. My name is Tom Boris. I'm the chief financial officer for one care Vermont. And thank you for the opportunity to come and present the 2024 one care budget. This is my seventh year presenting the one care budget to this, this board and board is time flying. We have a lot of ground to cover here. So we've structured the presentation into two parts. The first section is a high level tip to tail of all the key components within the one care budget. To give a broad overview and then we are going to dive in to a number of key investment areas that they've just mentioned and give you a little bit more information about the goal of the investment. How much, how we apportion funds, our approach, some emerging data that we're seeing and ultimately what we hope to see through time underneath these investments. So with that, let's jump right in please. Next slide. Macro level overview, the 2024 budget is largely consistent with 2023. This felt like an important strategy to us. We installed a whole new phm program in 2023, as well as the new mental health screening initiative. And it really felt important for us to provide some consistency to the provider networks that they had a chance to really understand and lean into the program designs. We have a similar network configuration. We have similar payer program terms and a continuation of most programs with only modest adjustments or enhancements. No change in this budget is a $2 million diva value based incentive fund that will again flow through one care Vermont. You may recall from last year there was an arrangement set up where diva would directly pay the providers based on one care program terms. In 2024, we expect these funds to again flow through one care, which means providers receive their payments from a single source. We are capturing savings from the analytics transition. This is part of the long range strategy, but the budget incorporates roughly 800,000 of cost savings. And in total able to offer a little over $2 million in hospital participation fee relief, which is a critical part of our sustainability strategy. Our budget starts with attribution, many program terms and payments going to the network depend on the attribution estimates. These are estimates that we prepared last summer. The big story here is in the Medicaid domain where redetermination is ongoing. And therefore we expect to see a drop in the attributed population entering 2024. This is simply a product of that process going on around the country. We expect similar attribution levels in the Medicare and commercial areas. And lastly, we expect all of these lives to qualify for scale targets under the Vermont all payer month. After developing our attribution estimates, we begin developing our total cost of care forecast. These are a product of attribution and the total cost of care targets. That will be agreed upon between one care and the payers or step by the screen man care board in the Medicare space over the next few months. The budget assumes the Medicare target follows the all payer model trend. This is informed by the United States per capita cost forecast prepared by the CMS office of the actuary. And in 2024 it is 4.48% but then less the 0.2% all payer model discount factor, which results in 4.28% trend. And in the Medicaid program, we have relied upon past years. We've been operating this program in a similar form for a number of years now. So we can look at our last few rate developments and provide a good estimate of what we expect the targets to be into 2024. Redetermination will lower the aggregate total cost of care estimate. However, due to the fewer attributed lives and then the commercial trends are based on either rate filings or for self funded. We've solicited some information from their health plan that they use for budgeting to estimate what that target might be for 2024. In total 974 million dollars of health care costs are in a value based care arrangement through these programs. I think that's a fantastic outcome. Something I'm proud of and really important to see us sustaining a large amount of total health care costs under an accountable framework. Next to speak about fixed payments underneath the total cost of care arrangements we have with payers. We occasionally have the opportunity to change the way the providers are paid. In 2024 we expect the Medicare and the Medicaid fixed payment models to operate in a similar form. Medicare reconciles the fee for service. Medicaid does not true fixed payment. We prefer the Medicaid model. We do not anticipate a commercial fixed payment option being available to us in 2024, despite our best efforts. Something I still push for and would like to see in the future. Taking a look at some data. I've showed here on the slide the split between how much of the spend in Medicare and Medicaid is in a fixed payment versus remaining fee for service. In Medicare about 51% of the total cost of care under accountability is in a fixed payment model in Medicaid. It's about 55. Some of the difference is due to different network participation. We have more hospitals who accept fixed payments in the Medicaid program than Medicare and drives that percentage up a little bit. When comparing year over year, very modest increase in the Medicare space largely due to inflation and then in Medicaid, it's a slight reduction. This is more of a product of just industry dynamics and re determination rather than a one care decision. In addition, there are 2 advancements in development that I'm really excited about the 1st and these were incorporated into the budget conceptually but not numerically just because at the time we didn't have sufficient data to insert numbers into the budget. But we are working actively with Medicaid diva in particular to develop a global payment program, which will expand the scope of the current Medicaid fixed payment. And in current state, the fixed payment covers the attributed lives and anybody unattributed remains a fee for service. So we've thought for a number of years now, wouldn't it be great to expand the scope of the fixed payment with Medicaid so that it covers all Medicaid membership and that means a provider accepting a fixed payment will have a singular paradigm for all their Medicaid lives or patients coming through the door. They'll all be covered by that fixed payment. So very excited about this advancement and we'll be happy to report more as we solidify the program terms and dynamics for 2024. Also, we are in discussion with a number of FQHCs about a Medicaid fixed payment pilot building on some of the concepts from the CPR or comprehensive payment reform program that we operate for independent primary care. So very excited about this initiative as well also actively in development and happy to report on this one as well as more information becomes known about who is participating and what the model looks like for 2024. Next, we have risk risk is a product of the total cost of care targets and the risk sharing terms we assume in our budget. We've assumed a 3% corridor for Medicaid and Medicare both with a 100% sharing term. And we've assumed similar risk sharing terms with commercial payers in this budget in total 26.4 million of total risk is estimated. It just happens to be very close to 2023. That was just a coincidence. And when we think about how we think about that total pie of risk, there are really 2 key buckets. First, we have the accountability pool, which is the way in which primary care are integrated into the risk sharing model about 9% of the total. And then the remaining 91% cruise to the risk bearing entity, which are the hospitals on behalf of their health service areas. Underneath the accountability pool, we've segmented into the non hospital versus hospital bucket just for informational purposes. That differentiation, the 5% versus 4% is simply a product of attribution to go a little bit deeper under the sharing model. The model incorporated in the budget is unchanged since 2021. Another opportunity for some consistency savings and losses are pooled and allocated to the health service areas. There's a performance incentive pool component of shared savings are earned that rewards HSAs for excellent outcomes. And then primary care organizations are eligible for the 1st $50 PM PM of any shared savings through the accountability pool. The budget incorporates the 1 care board of managers full delegated risk strategy to the provider network. And lastly, the budget includes continuation of the risk mitigation arrangement for Northeastern Vermont Regional Hospital. This was structured as a 2 year arrangement helped to bring them into the Medicaid Medicare program in 2023. And 1 care done this number of times over its evolution, offering some reduced risk levels in the Medicare program to help communities and hospitals on ramp into this model. All right, the previous slides were related to program terms that we expect in our payer contracts a little bit of how we handle risk and settlements. Now we're going to shift into a more operational space and we're going to start with revenues. 1 care has a limited few number of revenue streams at its disposal. The 1st are payer contributions. The funding levels are typically a product of attribution and a PM PM type arrangement with the payers. We're assuming the same PM PM arrangements stay in place. But as attribution changes, the amount estimated will go up or down. The other change I'd like to note this year is that again, the $2 million value based incentive fund pool flowing back through 1 care. So you can see in the bottom row of the top table that going from 0 up to 2 million dollars. Important to note, there's no change in financial opportunity for any of the providers, but the payments are now flowing through 1 care and that single source to the provider, participating in any 1 care programs. In the other revenue category. There's 2 would like to mention was the deferred revenue pool. In many of our program terms from prior years, there is obligated reinvestment in quality initiatives. So based on how the program settles out in the final results or some funds that 1 care must. Reinvest in the future. So we've accumulated a number of pools over time and are aspiring to use those deferred revenue pools to support the mental health screening initiative in 2024. And we'll speak much more about that program throughout the presentation. We've also started budgeting interest income over the last few years 1 care has often has a lot of cash in its accounts. It turns them over very quickly. Making those fixed payments to the provider network, but we do generate some interest on the accounts and we use any revenue interest revenue to help offset participation fees. It's ultimately a variable number and we've estimated somewhat conservatively in the budget here, but any any revenue we can bring in to help offset the cost of reform born by providers in Vermont. I think is a good thing. The last main revenue stream at our disposal is hospital participation fees. Really happy to report an 11% reduction going from 19.8 million down to 17.6 2.1 or 2.2 million dollar reduction. This is part of our sustainability strategy ensuring that the costs of 1 care born by providers in Vermont is as reasonable. When we look at breakdown of how the reduction in hospital participation fees was generated the bottom left chart tells the story. You can see the left most bar Arcadia transition. This is the analytics transition generating roughly 800,000 of savings. Next, we have operating expense inflation going up. It's about 2% on the total budget. Operating budget rather. Next, we have our population health model budget strategy. This is a little bit of how we're budgeting that program, which I'll speak about further in the presentation and also a product of attribution a little bit. And then a deferred revenue impact, which is how we're funding the mental health screening initiative in 2024. Looking at hospital participation fees over time. High watermark was in 2019 almost 30 million dollars. And then once the pandemic hit. In 2020, we canceled a number of initiatives and really thinned out and reduced down to roughly 18 million that year. We had a little bit of a bounce back in 2022 when the delivery system reform funds ended and the hospitals agreed to pick up the tab for the work that was ongoing. And then you can see between 2023 and 2024 trying to taper that amount down a little bit. Alright, now we're going to shift into the expense domain of the budget. Again, 2 different components here. The 1st speaks to population health expenses. These are payments that go to the provider network in support of 1 care programs initiatives. And the last one will be the operating expenses that make all this work possible. High level we're maintaining core initiatives from 2023 has instead at the top of the presentation here some consistency from 2023 to 2024 felt important due to the substantial changes that were installed in 2023. We have, however, made incremental changes to the population health model program to increase the weight on outcomes. This is part of a multi year strategy developed. Between 1 care management and its board of managers over time with input from the green light care board as well. Base payments are allocated based on attribution and they're moving from 475 PM PM to 425 PM PM while bonus potential is increasing from $1 PM PM up to 250 PM PM. Non attribution based payments. So this would be for any providers that don't attribute are updated with a similar shift to move more weight into the outcomes part of the program. And then we're assuming that 60% of the bonus payments are earning to speak about this in a moment. We are sustaining the 2023 mental health screening initiative. This was intended to be a 1 time program, but based on robust provider feedback, they felt like they just got their protocols up and running and would like to see the program sustain into 2024. I very much like this approach and idea allows to collect better data as well as we advance through this program. We budgeted blueprint expenses to increase by the all payer model trend of 4.28 same as the total cost of care target factor. And then we have included 200,000 allocated to support increased use of waivers. We'll speak about this a little bit more as well. But the waivers are incredibly powerful tools under the ACO framework and a little bit of financial support to help increase the adoption of these waivers feels like a great investment. When looking at the financial figures, the first thing I like to note is I've modified the 2023 column to include the diva $2 million funds so that this is a more apples to apples comparison between the two columns. A couple of highlights to note, you can see in the top row the bonus payment potential going up by a little over a million dollars and then the base payment component going down by 2.7. Some of this is attribution based, but some of it is our strategy for how to evolve this program through time. Next sizable investment is down a few rows to CPR program. I'm going to speak about this one as well. It looks like a reduction. It's more of a product of the accounting behind the scenes for this program, which is complicated. There's many funding sources that contribute to this program. This is a no way reduction in our commitment to independent primary care or the amount of funds we intend to deliver to them. Next, you can see sustaining the mental health screening initiative right around that 1.6 million dollar number and then bottom 3 rows represent the blueprint or sash payments that are inflating by that 4.28% factor. Okay, I want to speak about this concept a little bit. I mentioned before that we're budgeting 60% of the bonus potential. So 1 of the financial dynamics that we need to make sure we're mindful of and accommodating of in this model is that as we put more weight on the financial outcomes and results, it increases the variability in our expense base. So providers perform exceptionally well. They'll be higher expense. And if they do not meet targets, that will be a lower expense. So, our strategy is that we have budgeted. I'm going to look at the left bottom left column here, which is a breakdown of the primary care organizations or attributing organizations. Our budget strategy is that for the base component, about 7.2 million. We budget that in full. We know we have to pass those funds through to the providers. It's actually quite reliable expense stream for us. There is about 4.2 million of potential bonus payments that remain. However, based on the targets that are set, we do not expect that every single provider in the organization will earn all those targets. That would be a fantastic outcome and a good problem to have, but they are challenging targets. So we have leaned on our emerging 2023 population health model data and have estimated that 60% of the total bonus payments will be distributed in 2024 and a budgeted accordingly. That is a rough estimate. Candidly, we're learning a lot about the program as we roll it out in 2023. So this will be something that we look at closely. And as we have more data, we'll check this number to make sure that it is reasonable and sound as we get into 2024. To make it very clear, though, if the provider network achieves every one of these measures, 1 care is obligated to pay that full amount. That would be a challenging problem and that we would have an expense overrun, but also a good, a good problem that we had an excellent result. So something that is part of my job to manage in collaboration with the 1 care finance committee and board. On the right, we broken down this program. Again, this is the primary care PNPM part into a PNPM comparison between the 2 years. So you can see in the left column for 75 PNPM base $1 PNPM bonus $1 50 and shared savings potential to the accountability pool. Moving to 2024 for 25 base 250 in that bonus potential band, the same dollar 50 shared savings. So practices that met all targets in 2023 and 2024 would actually receive an extra dollar PNPM in 2024. Speaking a little bit about the comprehensive payment reform or CPR as it's known. This is a program developed by 1 care Vermont to offer a payer blended fixed payment option to independent primary care organizations. It began in 2018. Starting in 2023 of incorporated a linkage to total health care costs. And the reason for that being as total health care costs grow over time due to inflation and many other factors. Primary care reimbursement has not kept pace, particularly for independence. So by building in this linkage. It helps create a dynamic where as total health care costs go up. So too, does primary care reimbursement. The top left chart shows that in 2024 we are increasing the total potential for CPR participants from 9% of the total cost of care up to 10%. This was something we discussed with our finance committee and board of managers and they endorsed and supported an increase in the percentage being allocated to primary care. Just to be clear, it's not a 1% increase in revenue for an independent is 1% of the total cost of care, which is a significant amount. Operate chart shows how we fund this program 90% of the funding is facilitated through fixed payments. And that's why these fixed payments are so useful to us is that we can a portion funds are greater slice of the pie to primary care and help support them in our network. Some of the funds come from Medicaid contract and funds available through that arrangement. And then the last piece is rounded out by participation fees. Looking at enrollment over time. We've seen consistent growth. A little bit of an interesting dynamic regarding the 10s there or the tax IDs or entities drop in 2024. That's a product of one practice closed and ended. And another we've seen some consolidation of practices under a single 10. So number of practice sites continues to go up. Some business dynamics affecting that number of 10s level in terms of attributed lives hovering right around that $25,000 level little drop from 2023 anticipated due to re determination. This slide shows the population health funding sources and there are 2. One care is able to source funds from the payer contracts. That's about 17.6 million of the 25.7. And then the remainder comes from hospitals and the hospital funding is so important to us because it allows us to offer aligned financial incentives across payer lines. In other words, we offer the same PMPM model for a Medicaid Medicare or commercial life rather than having different levels of payment based on what the payer contributes to one care. So the hospitals are kind of the tool we can use to level the financial playing field across those different insurance lines. I'd also like to know the bottom 3 rows of that table. That's the blueprint payments and the sash. I put them under the payer funding column. But those funds are at risk in our Medicare program. And if the Medicare results were really poor in the year, the fund source for those expenses could actually flip to the hospital. So that's a kind of a dynamic aspect of this budget bottom. Okay. So now those were all the population health expenses going to the network. This is a slide about our operating budget. We have delivered a 3.4% decrease to the operating budget. Operating costs are fully funded by the hospitals or that interest income line, which is relatively small. No significant staffing changes. We do have a significant reduction in software expenses no longer needed as we transition to Arcadia. And ordinary scrutiny of all other expenses is it said no stone on turn we build this budget really from the ground up every single year. Valuing our resource needs relative to the work we anticipate for the year. Top right chart looking at operating budget over time. You can see aggressive growth between 2018 2019 and 2020 pre COVID. So once the pandemic hit, we canceled a number of initiatives and have lived in this $15 million range, but you can see since 2021 trying to taper this down over time. That's a challenging dynamic because there's always more to do every budget is an exercise in constraint because we see lots of opportunity for improvement engagement every single year. In the bottom section of the slide. I break down the analytics transition a little bit. Before there are really 3 categories that relate to this transitional effort salaries and fringe software and our contract with UVM health network data management office. No substantial change in the salary and fringe line. These are positions that liaise with UVM and ensure that the ACOs needs are met. But you do see a significant decrease in the software category just over 1.5 million there. Not only end our health catalyst arrangement, but there are a number of other contracts that we had to buy in the past that are integrated into the Arcadia platform and that represents an opportunity for cost savings. There is an increase to the UVM H and contract that is just part of this transitional process of a little over 750,000, but the increase in that contract is much less than the savings generated through the software. Changes and that's how we're able to deliver 800,000 of cost savings to our providers. Okay, so that was the tip to tail of the major components and the one care budget and now we're going to really focus in a little bit more on our investment areas. And the goal here is to show you a little bit about why we're investing in certain areas. Our goals, our approach, some emerging data and what we hope to see in the future. The 1st main investment area is our population health model program. The goal of this program. Is to improve population health outcomes and quality scores. The approach that we take is to try and align focus across the provider spectrum on key population health outcomes, including 1 carers payer contracts and the visual on the bottom right. Kind of shows what I mean, trying to get primary care, home health, days, triple days, all working on some aligned or similar measures under the concept that if we're all focused on some of the same things, we can drive greater improvement. We provide basic payments and bonus payments to organizations meeting targets. This is the incentive model to try and generate focus and energy behind the initiative. And then we provide data and reporting and current performance and analyses to help organizations improve outcomes. Really excited what Arcadia will be able to deliver in this area in the future. The program includes primary care organizations, home health agencies, designated agencies and area agencies on aging. The program in total about 14 million funds that go out to the provider network. 12 million is pre funded based on that concept. I spoke of earlier. Top right chart. I've showed the total dollars on a PMPM basis just because attribution will cloud the macro level numbers, but in total modest increase between 2023 and 2024 total funding potential. Moving from $6.96 PMPM in 2023 up to $7.77 in 2024. In terms of how the funds are allocated primary care organizations receive a 425 PMPM base and that 250 PMPM bonus. For non attributing organizations that are aggregate pools established to the budget process for the same as last year. 75% of that pool is the base that is allocated out based on proportion of spend. And 25% is that bonus pool dependent on outcomes. Providers under this program are expected to actively pursue meeting the population health model measure targets. And fulfill care coordination obligations and lastly engage with 1 care on improvement activities and try to bring the network together. Talk about challenges and opportunities and provider engagement is always great to see. So here's what we hope to see through time and some of these will be generated over multi year span. We always take a long range of you with these initiatives. But we hope that this program will drive increased population health model measure results by practice. Increase results by measure. Increase results across a whole HSA where the whole HSA is working hard on these and generating better outcomes. And then an increase in relevant quality scores and payer contracts. And this is how we really evaluate the effectiveness of the initiative. Opportunities. Every one of these programs has the opportunity to advance through time. The three that felt important today are to continue advancing the partnership in line with blueprint. There's a lot of really good work going on there that Dr. Kerry Wolf will speak about a little bit. Leveraging Arcadia to deliver advanced data and insights is something that I'm excited about for 2024 as well. And then as I mentioned before, maintaining focus on challenging areas over multiple years. None of these problems can be solved in just a one year sprint. So really this is a marathon process to try and improve the outcomes over time. All right. And then from here I'm going to hand it over to Dr. Kerry Wolfman who is going to speak a little bit about how we select the measures, how we're integrating or engaging with our provider network and some emerging data. Thanks Tom. Good morning. In selecting our clinical quality measures for the population health model in 2024. We had to give consideration to these areas. What data is available? What's in our payer contracts? How are we performing both now and in the recent past? What's our ability to influence the results? What's the provider burden? We also have had a lot of discussion about standard measures versus custom measures. We want our measures to be applicable across populations, payers and the continuum of care. And then we've received and processed a lot of feedback from our providers about how this program is going currently for 2023. The percentile targets for 2024 are chosen based on national benchmarks and they're set relative to current performance levels based on our data. And the selections are also cooperated by our benchmarking and evaluation report outcomes. We've also gained insight by meeting with several similar ACOs for peer-to-peer learning. We've explored best practices with them and plan on doing more of that in the future. This is affirmed that we are actually using some similar strategies in areas such as ED utilization and primary care access. For example, embedding care managers in emergency departments is something that high functioning ACOs are utilizing. And we have seen some of that here in Vermont, but there's more room for improvement in that area. We're also learning that approaches to team-based care are key in improving patient satisfaction. Next slide please. This chart shows the evolution from the focused areas, the incentivized quality areas from 2023 to 2024. This is a very dense slide and I'm not going to go through all of the detail here. But the left-hand column shows the current 2023 population health model measures that are incentivized. And then the next column shows the 2024 measures. As we move from this year to next, we are mindful that we want quality measures that are claims-based, that are standardized, that are targeting national benchmarks, that maintain our focus in the key areas of wellness prevention, chronic disease management, ED utilization, and mental health. We are also sunsetting inverse measures because it's just not intuitive that lower is better and we've heard a lot about that in our measures for this year. I want to point out just a couple of things on this slide, but not all of the detail. The first row is Diabetes Port Control. I'm very proud to say that our focused work across the state of Vermont, all partners pulling in the same direction, have improved that measure to the point that we've kind of topped it out. We're greater than the 90th percentile in the diabetes measure, so it's still part of our annual measures going forward, but it will not be included in the 2024 PHM. The second row talks about hypertension. This year, we have a custom measure on a process improvement in getting people with hypertension back into the office in a certain timeframe. Next year, we will be moving back to the standard measure of controlling hypertension. It's frustrating, but this is a measure we have not been able to move successfully in Vermont over the past few years, so we really want to focus in on it this year with all of our partners. And then thirdly, the third row I want to point out is a measure FMC is the title of this HEDIS measure. It is follow-up after emergency department visits within seven days for patients with multiple chronic conditions. And we are incentivizing that in 2024 across the continuum of care. We really want to see everyone working together to improve that measure. This measure is a proxy for controlling costs. We also know that success in this measure decreases ED revisits as well as admissions. One more thing on this slide I want to point out. You will see in the 2024 column, if you go down, there are two blank spots in the 2023 column. And next to that for 24, we are including initiation of substance use disorder treatment as well as the engagement. They are two separate measures. We have performed the most poorly on these measures over time. And so we want to incentivize work on these measures for 2024. Next slide, please. One of the main levers that we have to drive reform strategies is to engage with our network. So in 2024, we have 10 scheduled meetings and we are asking our members to engage with us in at least 50% of these. We have some of these meetings now and these are set already for next year in our planning. We have created data sharing opportunities with a set schedule. And for this year in this first category, HSA executive consultations, we just completed our fall rounding. These are one and a half hour HSA level executive presentations of performance in the quality and care coordination areas as well as the finance areas. And I'm very proud to say that just in October, and then we had one meeting just this week, the last one for the fall, we had more than 140 participants around the state who participated in discussions and looked at this data with us. We have increased our invite list for these meetings to incorporate leaders from across the continuum of care. The second category of required meetings are our quarterly value-based care webinars. Those have gone really well this year. We've had great attendance. This is where people come together to share best practices and learn from each other on what is and isn't working. The membership at these meetings include our own value-based care team, that's quality and care coordination, practice managers from across the state, all types of providers and continuum of care population health leaders. And then the third category of standing meetings are our quarterly population health model performance improvement meetings for 2024. And that is basically a mini version of the executive level consultations. We bring our data, which has been analyzed, we bring our most recent care coordination reports, and we have a conversation with the local health care reform population health teams about how things are going. This is an opportunity for all together around the table, talk about what's working in the HSA, and talk about potential areas for improvement. Next slide, please. We are working to ensure that resources go to the right place for care coordination. And as Tom already told you, care coordination and meeting the requirements of care coordination is part of the population health model. It's essential before any of the incentivized funds can be accessed. We're using our data-driven support to ensure that people with certain patterns such as high ED utilization, high in-patients utilization, high total cost of care, and high social and medical risks are being offered care management and that they're engaging. So this slide shows that from 21 to 22 in all four areas, there has been an increase in the number of patients, the percent of patients who are engaged in care management. This work I want to point out relies on strong partnership with the Blueprint and other collaborators. And I just want to publicly credit those entities for the work that they're doing on care management across the state. Our 2023 evaluation, which I will touch on a bit more later, confirms something we already have known, and that is that an interoperable communication tool really is essential for improvement in this program going forward. It's also essential for provider satisfaction. Next slide, please. This is the third year we have asked Vermonters who are engaged in care management to participate in an annual patient experience survey. I believe we've had more than 221, more than 322. I can get those numbers if you want them, but we've had good participation in this survey. And this slide shows that over time, those in care management are responding positively about their experience with care management across Vermont. And we take that as a very good sign. We invest a lot in this. The state invests a lot in this. And most importantly, it seems like the patients agree that it is helpful to them. Next slide, please. So how are we doing so far in 2023? Early results and signals in the population health model show that there are some positive signs of improvement while also indicating there's ongoing room for improvement for sure. Of the five claims based measures, you can see here that four of them have shown improvement this year between quarters two and three. The gray bars represent the base period or quarter one where pay was for reporting only. But if you look at the annual wellness visits, the child and adolescent well visits, ED revisits and hypertension follow up. We seem to be making progress this year by incentivizing these areas of work, which is really encouraging. There's, again, you can see here very little room to improve in the diabetes A1C control measure. The value based care team is using this data right now meeting with people around the network who are working on these to try to push people to truly attain the targets, both in the quality work and in the incentive payments by the end of the year. We fully expect that we will see additional progress and improvement when we collect the quarter four results. Next slide, please. This slide is just an example of the quarterly population health model practice performance report. This report is released quarterly at the practice level and then we meet at the 10 level to discuss it. We also bring the most recent care coordination reports to these meetings and we talk with those people working boots on the ground to improve these areas of care. So you can see here this particular practice is improving in the child and adolescent well visits. They've earned some money for doing that. They have room for improvement in developmental screening and this shows they still have money on the table. We're very excited and looking forward to utilizing Arcadia in 2024 for similar reports to what you just saw, but they will be at the HSA level. And now I'm going to pass it back to Tom, who is going to discuss with you more about the comprehensive payment reform program. Thank you, Kerry. So the second main investment or key investment area here to discuss is the conference of payment reform program. I spoke about this a little bit at a high level previously. The goal of this program since its inception in 2018 has been to support independent primary care practices to advance primary care delivery and remain financially viable, which was very important. Our approach is to replace fee for service with a payer blended monthly fixed payment. Connect reimbursement to the total cost of care and increase the amount allocated to independent primary care practices. And then in 2024, we're continuing to offer financial incentives to expand services offered by independent primary care practices. And we do that in two ways. The first is that for practices committing to mental health integration can receive an increased percent of the total cost of care. And then there's a 5% premium of what we call non-core services, which are services outside of your standard primary care services that many primary care practices offer. And we like to see expansion in that space, for example, more behavioral health or mental health supports. Organizations are all independent primary care practices participating in the Medicaid and Medicare programs. There is an exemption for pediatric only practices that wouldn't otherwise be in the Medicare program. The total cost of care is available. 9% of the total cost of care is the base. And then there's a half percent advancement for practices agreeing to the tier two concept and an additional half percent advancement for tier three practices. And tier three means that the practices committed to mental health screening and also developed a staffed or partnership model to support patients with their mental health needs in the primary care setting. And then offering 105% fee for service for non-core services. This allows practices that mid-year want to invest in more services such as that behavioral mental health support to have their payments for up throughout the year. Funds are a portion to each practice based on their attribution, that percentage of the total cost of care. And then there's a risk score adjustment for the adult population. And we use an age gender matrix for the attributed pediatric population. Provider accountabilities include all the population health model accountabilities previously discussed for practices receiving the advanced tier payments. They must fulfill their mental health screening and integration expectations. We expect that they will participate in our CPR clinical advisory group meetings, which is a newer group established in 2023. And then engage with one care to help develop the program design each year. This program has come a long way over the 7 years it's been in operation. And it's really informed by provider feedback and input and really hope that providers give us their candid thoughts so that we can make it better and better each year. For financial results, we are seeing that all participating practices benefited financially from the program in 2022 and the same result is projected in 2023. We've asked the participants for some input in terms of how they're using their funds and they reported that about 59% of their additional funding is used to support new activities and really expanding the services offered in the primary care setting. With the remainder sustaining existing activities uncomfortable with both, but really encouraged by almost 60% towards expansion. The right feedback is participant reported uses of those funds and I'm encouraged to see increase in staffing levels for care coordination. Mental health initiatives and other really important activities and some practices were were candid and said they're branded to the program. They haven't had an opportunity to invest. So that's a signal to us to really work with them in 2024 and ensure that they're maximizing what they can do underneath this program. So these are emerging data. I'm very excited by the 2023 population health model program and what we can do with it. So this is designed to show you a little bit how we can use our phm. Model data to support our CPR program and practices as well as everybody else, but just because this is relevant to the CPR wanted to dive in a little bit here. We looked at a couple of the practice specific measures in the CP and the phm program in 2023 and trying to really learn the difference between the CPR practices versus non CPR practices. So a couple of interesting observations. Again, these data brand that we're just kind of ingesting them and making sure we understand them fully. But what we found so far is in the annual wellness visit domain, the adult and family meds CPR practices are not performing as well as their peers. I find that very interesting. Regarding child and adolescent well visits, the pediatric CPR practices perform really well better than their peers. But the family med practices are generating about similar results to their peers and also lower than those pediatric practices. Same pattern holds true in the developmental screening area. So I find all of these information very interesting for next steps. I'd like to leverage the CPR clinical advisory group to understand the barriers to annual wellness visit results. I have some hypotheses, but I really want to hear from the practices. It's their opinion that matters most. I think we should be exploring the differences between family med and pediatric practices related to the child and adolescent well visits and developmental screening. It feels like an opportunity to see if the family med practice might be able to learn something from the pediatric practices or or maybe there's a just an industry barrier that exists there. And then based on what we find and learn from the practices, we can consider whether or not we want to incorporate some sort of accountability or financial component into the future program design. We regularly ask for feedback on the program. It both helps make sure that we're doing a good job and also inform the future of the program. In terms of the positives, the fixed consistent payments and increased funding available to practices were common. There are some pros of the program on the con side, a little bit more diversity, but complexity of funding was one that's frequently mentioned. I can appreciate this because it is a complex model behind the scenes. Hope to make it simple for the providers. Contract and data transparency, data timing, and then concern for program expansion costs as well. The response actions from these reported feedback items. We've already installed a couple of these. We, we've developed periodic meetings with each participating practice to review financial and clinical results. I hope that this helps to address the complexity of funding a little bit more at the support so they can understand the financial model financial results. We have developed that CPR clinical advisory group up and running. This is a group where we can discuss clinical outcomes and really hope to improve and look at the data I just showed in the previous slide and hope to improve on those in the future. And then the development of Arcadia is a strategy to help enhance data delivery. I think that could help with the data timing concern. We can't solve it completely and that claims run out as a real thing in the industry, but hopefully Arcadia helps to deliver more real time information of those practices and supports their improvement efforts. Results indicators. Here's what we hope to see through time is that the CPR program payments are greater than fee for service, enhance revenue for these practices. We'd like to see improved PHM performance. We know there's opportunity there, but excited to lean in strong engagement in one care meetings and initiatives from the CPR participants. Provider satisfaction with the program design is really important. We've actually surveyed the providers based on things like burnout to see if there's something that this program can do. And that practices remain financially viable. There are many factors to that, but we want to do our part to keep these independent primary care practices in business. Opportunities for the future. I think we need to continue advancing the financial model relative to the total cost of care. That's a much more complicated concept than. And it sounds occasionally. I'd love to reintegrate a commercial fixed payment into the model. If 1 is available to us. This is actually probably more important to me in some ways than hospital fixed payments. So the way champion both and elevate and evaluate and evolve the mental health integration model implemented in 2023. This is a brand new concept installed in 2023. We're learning from it. We're collecting data and feedback from the practices. So we intend to really dig into this over the next few months and see if this is the right model and concept to continue into 2025. And with that, I'm going to hand it back to Dr. Wolfman to speak about our mental health screening issues. Thanks. I'm mindful of the time. So I'll go speed up a little bit. Let me know if I'm going too fast. So in keeping with our commitment to paying attention to mental health care in the state and access to mental health care through the focus both in the population health model in 23 and 24 as well as the CPR program in 2023 and 24. We designed the mental health screening initiative for this year. We thought it would be a pilot for 23 only. But we got provider feedback that now that they have put their protocols into place, they would like at least another year to implement what they've built. The goal of this screening initiative is to standardize mental health screening across the state and standardized data collection protocols across primary care organizations in particular. The approach in 2024 will be a little different. We have had already three discussions with the blueprint and we want to align with the blueprint expansion project for 2024 on screening processes. We think if we keep our program exactly the same as this year, we might be duplicating efforts and we don't want to do that. So we are aligning and having great conversations about how to do this. We have not yet decided on how to set up the financial incentives, but we will solve that before the year starts. We will continue collecting screening rate data to help inform opportunities to further mental health care integration. And this will be structured as for this year in a payer and attribution agnostic way. So patients will get screened regardless of whether they're in the ACO and not dependent on the payer. The primary care organizations within our network all are eligible to participate and the funds allocated are over $1.6 million for 2024 in the budget. Next slide please. The allocation will be about a dollar per member per month paid into installments. The provider accountabilities will be to integrate eligible mental health screenings into their workflows across all patients and to report on the screening and referral rates via electronic reporting. This is key. This is one of the first times we are allowing people to use their own electronic health record for real time quick turnaround reporting so that we can have the data more quickly. Indicators that we will be getting the results we want are that we will see an increase in the percentage of eligible primary care organizations committed to doing this work. And we will see an increase in the screening rates across the provider network. We have opportunities we recognize in standardizing the data reporting. And we have opportunities to set screening rate targets. And then in the development of the protocols and pathways there's a lot of work still to be done. Next slide please. So far in 2023 we've gathered some data about 80% of primary care practices attested to participate in the mental health screening initiative that we set up as a pilot in 23. And based on data submissions through September the average baseline screening rate was 34%. But you can see here there's a wide range all the way from four up to 100%. Some of these practices have many fewer members than others. So that's a point we want to make. And our response to this is that we need to take a close look at the reporting. We think there is some significant variation in the way that the data has been collected. I think that will be corrected and that by the end of December this will look very different. We've already had discussions about those who have the low reporting and have identified some of the reasons for that. Again going forward we want to align with blueprint on this initiative. And we want to engage. Hopefully we will get 100% of practices to participate in 2024. Next slide please. We want you to know also about some additional ACO contributions to healthcare transformation that are already in action. Next slide. We committed in our 2023 budget to invest in an independent evaluation. We just received the final evaluation report from Sinashore. That's the group that was hired to do this evaluation. And I believe you received that entire evaluation in the last week. And we have the high level strategic considerations made by Sinashore in that evaluation report are listed here. And we know we have opportunities in these areas. Develop a multimodal communication strategy that continually emphasizes goals, approaches and progress. And become more organized in doing that. Bolster our relationships with statewide stakeholders such as the blueprint and department of mental health and explore new ways to influence statewide policy and planning. And then to develop explicit transformation targets and to hold practices accountable. Something that we have already set out to do for 2024. So by quick review of the results in this report, we're very excited about the confirmation that we're contributing to success in certain quality areas, which we will discuss with you when we meet. And there's a lot more work we can do and that we want to do. Next slide please. So we've set aside $200,000 in the 2024 budget for future waiver implementation. This is a special funding area relative to our fraud and abuse waiver implementations. Wavors of fraud and abuse laws allow us to share risk to share money and savings as we've been doing since we set forth and to share data. They also allow flexibility and efficiency in the delivery of care to our patients and they allow us to pay for things for patients that otherwise would not be allowed. And we've seen some really amazing work in this area with utilization of the waivers through the ACO. Some of these waivers are designed by Medicare such as the skilled nursing facility three day waiver, which I know you've heard about. I'm happy to let you know that 61 patients have been admitted to skilled nursing facilities for rehab since May with use of that waiver. That means for those 61 people, we saved at least one hospital day, if not more. We are working on that data and trying to find out the specifics, but we know it has lowered cost and we know that it gets patients to the right place for their care more quickly. Going back up a little here to waivers that are designed by one care along with our participants to meet specific needs in a community. We have a great example of that, which you probably read about in VT Digger, the ambulance transport project, which is a partnership between hospitals. Several hospitals have been involved in the agreements between the hospitals Brattleboro retreat and rescue Inc, which is an ambulance service based in Brattleboro. 204 people who are ready for voluntary treatment at the Brattleboro retreat have been transported with this service. Very positively impacting emergency department wait time and obviously patient satisfaction. They don't have to wait. They get to the place they need to go for treatment in a much more timely manner. This also opens up ED beds and potentially inpatient beds as well and gets patients to the Brattleboro retreat in a timely fashion. So the staff waiting for them there on on duty waiting can see the patients more quickly. So all around a real win for quite a few patients. Other ways we've utilized these waivers, which are doing a lot of good for patients as well as hospital throughput is we're able to use these waivers to pay for things for patients that we normally couldn't pay for. One example is there are patients often waiting in the hospital that need to go to a skilled nursing facility, but there is some some barrier. One of those barriers is that IV drugs that are needed for ongoing care are very expensive and that impacts sometimes whether or not a skilled nursing facility can and will accept a patient for admission. Hospitals can now with use of this waiver and board approval at one care pay for the IV drugs to get the patient moved out of the hospital and to the SNF in a more timely fashion. We could. We've also utilized these waivers to get nutrition consultations for patients on Medicare who don't have access to access to them otherwise because they're not covered by their insurance. And something else that's very useful and that I think we need more of is paying for personal care assistance for patients when they leave the hospital. A lot of patients don't qualify for home health or skilled nursing, but they still need some help at home. And sometimes that is the main point that is prohibiting them from discharge. So all in all, many wonderful things are happening with utilization of these waivers. We plan to continue leveraging our waivers and innovation workgroup as well as our board to direct the use of these allocated funds for 2024. Next slide please. We have invested time and energy this year in building relationships with health care partners. And I believe this is a role where we have room to improve even more as we go forward. One of those examples is there's an ongoing stakeholder skilled nursing facility focus group that we've participated in along with the Department of Disabilities, Aging and Independent Living, as well as the Vermont Health Care Association and others to work on collaborations regarding the provider coverage shortage for skilled nursing facilities. A second example in early stages is a collaborative group of health care partners that are meeting to discuss alignment for Vermont on screening for social determinants of health, a very important and growing area. We need work in this area so that we can uncover and then address health disparities in our state. The first meeting was hosted by One Care in October. We invited key partners from payers including Medicaid, Blue Cross, MVP, provider organizations, Home Health and Hospice, area agencies on aging, Vermont Medical Society, state government. We had blueprint participation there. We had data governance people from the state government, UVM, population health service organization representation, as well as practicing providers to have leadership roles in our decision makers in this area. We had 25 people or more there, at least half were in person. We shared screening tools, they vary, and we also shared requirements, regulatory requirements that some need to incorporate into this decision making. We discussed the shared goal of aligning on a standardized tool on digital entry of this data and on data governance. There is an agreement with this group that data is needed before we can design solutions. And I was just really excited at the amount of positive energy at this meeting. Leaders are really engaged and care about this work and they voiced a flexibility and a desire to work together so that we can hopefully align. The next one of these meetings is scheduled for January 5th. And one of the main points about this work is as we uncover and address health disparities, this requires data integrity along with intentional and lawful data governance. So that is always top of mind. And next slide. This is my last and perhaps most important slide. We support the move to the quintuple aim, which includes excuse me just a moment. As you can see depicted here, the quintuple aim incorporates clinical outcomes, patient experience, provider satisfaction, financial sustainability and health equity as the fifth aim. Equity and access are integral to all population health efforts and initiatives at one care. Our HSA consultations include HSA specific disparities data and for 2024 our new platform will improve the data integrity and scope in this area. We've also built access it assessing health equity into our provider accountabilities for 2024. And I just want to leave you with the definition here at the bottom. The CMS definition for health equity is the attainment of the highest level of health for all people where everyone has a fair and just opportunity to attain their optimal health regardless of various factors. Vermont has the opportunity to align and shine as a national example in a lot of this work and just want to say thank you for listening. All right, I'll just round this out before handing it back to a for a minute and just in summary of everything we presented this budget thoughtfully balance the sustainability reform efforts relative to cost cost controls important to us and we've heard from you as well as this Green Mountain care board. We have over 970 million of total costs of care of spend in a total cost of care accountability framework. We're sustaining the main and core phm initiatives we've incorporated incorporated the analytics transition that corresponding cost savings 3.4% operating costs decrease 11% participation fee decrease reducing the cost burden of Vermont providers. And at the end of the day it's a break even model with no additional contribution to reserves. Thank you, Tom. Thank you, Dr. Wolfman really appreciate all the work that you put into this presentation. We presented a reasonable and balanced budget that allows to continue to support the goals that all pair model help our participant network and provide value for monitors in the coming year. It sustains funding for our core population health management programs and key initiatives like CPR and the mental health screen initiative you just heard so much about. It will also help us expand the use of waivers that cut through red tape for providers when they seek to provide high value care to their communities. And I think it puts more emphasis on quality measure and total cost of care performance than in prior years, which is something you've asked us to do. As always, we're going to continue to work to align incentives around the quintupling and break down barriers for providers as they collaborate and innovate in the coming year. We appreciate your time and your support and we welcome your feedback. That concludes our presentation. Thank you. Great. Thank you all very, very much. It's a nice presentation. I appreciate it. Why don't we take a five minute break and then we can come back with some questions from Michelle Sawyer. So we'll come back at 1126. Thank you. Maggie, are you back? Yes, your honor. No, your honor for me, but thank you. I'm sorry. Just so one works. Okay. So you're ready to go back on the record? Yeah, Mr. Berman, do you have everyone you need? I believe that we do, yes. Okay, great. Yeah, Maggie, we can go back on the record. Thank you. We are now back on the record. Okay, I know, and Abe is fine for me as well. Okay, great. Miss Sawyer, I believe you had some questions. Please go ahead. Thank you. All right. Dr. Wolfman on slide 25, you'd shared some improvements in care coordination rates between 2021 and 2022 for the subpopulations of focus. And in the submission, these rates were also shared for 2023. And for a couple of those subpopulations, the high cost members and the high SDOH and medical risk, those continue to improve for 2023, which is great. The rates of care coordination for the high ED utilization and the high inpatient utilization did go down for 2023. And I was just curious if you've been able to determine any causes of these trends for 2023. I have not yet spent time looking at causes and I've also been told that the full reports for 2023 in these areas are not compiled yet. So I'd have to look and see what information you are looking at in the materials we submitted. I just asked a colleague yesterday if we had all of the information for 2023 and it's not compiled yet. Sarah may know something else about that, but to my knowledge, I don't have all the information yet for this year. And I have not spent time looking at why the preliminary data go down in those two categories. Okay, that's helpful to know that those might get updated, which makes sense. The year is not over. Another thing that was mentioned about care coordination and the staff had sent. Oh, Sarah. Sorry. Hi, Michelle. I just wanted to add that we will have updated data come January of 2024 for the 2023 year. We'd be happy to share it. Perfect. Thank you. So, relatedly, we had in the follow up questions asked about the reference made and it was made during this presentation as well about the need for an interoperable care coordination tool. And I didn't know if you were able to share any, any more. It sounds like it's a multi stakeholder engagement process. And, and, you know, it sounds like a wonderful thing that's really needed for the network and I was curious if you were able to share any additional information about what that might look like. And I think we're in the, in the process that group of folks is at as far as determining what's next. I think I could respond to that. It's going to be a long process to figure out an interoperable solution. So, as we mentioned in our responses, there are a number of stakeholders and we really feel like lessons learned from our prior experience mean that we need to coordinate well with all of these partners. And so it's clear for us that there won't be a new investment in 2024, but that what we continue to explore our possibilities using an integrated approach with the HIE in Vermont. Also thinking about future strategies as we roll the Arcadia platform forward and what that possibly could look like. But I would say we're fair way away from identifying together a top solution. Okay, I'll be excited to hear when there is more information and see how that progresses. Great. I wanted to ask about the longitudinal care program. The budget narrative described the program getting back on track for 2024. It sounds like there was some pandemic related workforce challenges in the home health area. The healthcare has budgeted $399,000 for each year for the past few years for this program. So I was curious how that program functioned after its initial pilot in 2020. Did it end up spreading to other HSAs given some challenges it sounds like this program has had? And how was that money spent during these years when that program was kind of, it sounds like not operating as perhaps was intended? Thanks for the questions, Michelle. I think there's been tremendous learning in the longitudinal care program space. A lot of the really early successes were interrupted by the pandemic. And as you mentioned, a lot of workforce challenges emerge. So during those couple of years, what we found were really, I would say, two significant changes. One was kind of expansion and contraction happening in different communities as we were trying to roll out and expand the program. And that was really dictated by fairly last minute impacts on staffing. And in addition, the original model that we've had established with the home health agencies for data collection allowed for individuals who were both attributed under the ECO and not attributed to benefit from this program and have expenses paid. And with some of the staffing changes that happened during the pandemic, that data collection model disappeared. And it meant that we were not really able to get the insights that we were looking for around some of the utilization and cost outcomes. And so working together with the home health agencies this past year, we made a collective decision that we needed to refocus that program and narrow it to attributed lives so that one care could take responsibility for being able to analyze the data and the impacts. And so that change went into effect this summer, and we have communicated and come to agreement that that would be in place for 2024 as well, hoping that that gives us the more clear data on outcomes that we are seeing when the program first launched. Thank you. That's helpful. It looks like that preliminary data was very promising. So fingers crossed that continues. Great. Let's see. A question about the relating to the benchmarking report, the Medicare benchmarking report, and really around budget target number nine, which in the budget guidance. It asked one care to choose three metrics in response to your performance in that benchmarking report, three metrics to really focus on, and your budget narrative explained what those metrics were and how you were addressing performance in those areas. I was curious if you were monitoring their payer performance in those selected areas, given that that is a Medicare only benchmarking report, but were you looking at how you're doing across payers in those specific metrics? Thanks for the question. I think the metrics align really well with what you've heard this morning about our continued focus in our population health model, the metrics being around ED utilization and primary care visits. And so from that standpoint, we can assess the payer differences on an annual basis through some of the scorecard data that we work with payers to collect. And we also can look at certain subsets, particularly when it's playing space. So we could use a payer specific strategy to look at that information. When we do, we do tend to see some variation and it's not consistent. So we haven't really been able to identify necessarily what all of the root causes are. We've seen some variation that was yet to be fully explained. Great. Thank you. Chair Foster, I believe that was the last of my questions. I'll hand it back to you. Thank you. Great. Thank you. And I'll open up to the board for any questions board members may have. I'll go ahead and start if that works for you, Chair Foster. Please. Great. Hi all thanks for joining us today. So I wanted just one piece of clarification around the six provider accountabilities that you've outlined in terms of ensuring engagement of the provider network. Do they apply to all provider types? So DAs, home health, everyone in the network or a subset? I'm happy to take that one again. Globally, they apply to all of our network, but there are nuanced differences. For example, in the provider accountability around technology, the requirement for 2015 cert certification is really specific to attributing providers. Thank you. And Robin, I will just say this because it's it's one of my sticking points. Provider here means 10 level provider, not clinical provider. Thank you for that distinction. And I should have said this at the outset. If any of my questions veer into confidential or negotiated negotiation related information, please just let me know and I can hold the question for an executive session. I was curious about the status of your arrangements with the ambulatory surgery center. And I know in your submission, you were indicating that you were working on some program structural changes. And I was just curious to get more information about that if you were able to provide it. Sure, I can take that long. At least from a financial standpoint, we installed a fixed payment arrangement with the Green Mountain Surgery Center in 2023. I think both organizations are learning from this program initiative. We've actually seen some kind of dynamic results in their spend patterns that we worked with them throughout the year to understand a little bit more. We'd like to continue the relationship into 2024 and just continue building on what we're learning about their business and the drivers behind their claims levels and the services that they're doing there. So it's really just building on what we've developed in 2023 and continuing it through to 2024. Great. Thank you. And my apologies, my questions are sort of spread throughout so you'll have to bear with me a little bit as I find them. What are the areas I was interested to learn more about is the collection of some of the quality reporting data and how much of that collection at this point is electronic from the provider versus the ACO supporting manual claims, clinical data extractions just to get a little bit of an update on in terms of some of those reporting burdens at the provider level, whether there's been some advancement in terms of using the EHRs for electronic reporting. Just noting that Medicare is increasingly requiring electronic reporting. I wanted to get kind of a new baseline of where we're at with that. I'm happy to start that. And then somebody else might want to chime in. So in the population health model for 24, there's only one measure that is not claims based. And that's the hypertension controlling hypertension measure. And we are working on the protocol to allow practices to report that out of their electronic health record. So as far away from manual abstraction as possible is our goal over time. And we're getting there. We've made a lot of advancement in the last two years in that regard. I also told you during the presentation that the mental health screening initiative is a foray into this area. It was one of our high level goals for that initiative was let's see what we can accomplish here with quick turnaround EHR reports and learn from that. So we'll have more to share about those learnings later. When it comes to the annual metrics there will still be manual abstraction necessary. There are more clinical measures in the annual metrics than there are in the population health model metrics for 24. So ongoing diabetes is a clinical measure that A1C control hypertension again is in there and few others as well. You're muted Robin. Thank you. One of the things that I've been noticing as I'm learning more about what's happening nationally in Medicare fee for service is the submission of clinical quality measures through ECQM. Is that something that you think our providers are currently using or not really so much yet? I would say our knowledge is a little bit limited. But anecdotally I do not think a lot of providers in Vermont are using that yet. And part of that is the all clear model framework. Exactly. That allows for the effort. Okay, thank you. That was my assumption, but I just wanted to test whether that seemed right based on your information as well. So in terms of the transition of the two million value based care incentive fund from Diva. I was just wondering if you could give us more information about sort of that switch because it used to go through you then it got pulled out and now it's going back through you. So what learnings have kind of driven that evolution? Sure. So I can speak to it from the one care perspective is that I think it's always been our preference to have this single source where for all one care programs we're making the payments that providers that means they get them all at the same time. It simplifies the payment statements that they receive because we would show them for example the amount they should expect from Diva later and just one more thing for them. To track so in throughout 2023 we did work with Diva to develop the protocol where we would submit a file to Diva saying here's here are the practices to pay and the amounts to pay. They would ultimately make those payments. But there's just timing differences when we made our payments from everybody else. And I think through our ongoing collaboration work with Diva. We agree that it was a better framework to have these funds come back through one care that which is always our preference and I'm sure Diva would have more to offer to that question but that was our particular perspective. Thank you. In terms of that. So you had mentioned earlier in your presentation that you're assuming the blueprint programs will be extended the same trend as the Medicare benchmark. Are you including sash as a blueprint program in that statement. Yes I was. Thank you. Sorry for my words. But yes. Okay. Some people do and some people don't. So I just wanted to clarify. Okay. Thanks. I wanted to talk a little bit about risk. So last year. Well let me back up. There's been this ongoing issue around the blueprint and sash Medicare contribution coming in through the total cost of cure benchmark as advanced shared savings and the dynamic that creates at the HSA levels with the hospitals feeling that is asymmetric risk. And I think part of the reason behind the budget target including a shift of that risk amount to the ACO level was to alleviate that asymmetric risk concern that we've heard repeatedly from hospitals and quite frankly from you all as well. And I understand your risk model is a delegated risk model and I understand and it quite frankly that makes a lot of sense to me but I'm wondering if you could just speak a little bit more as to why it doesn't make sense to you to solve that asymmetric risk. Model by shifting that risk to the ACO level as opposed to continuing to have that be an issue at the HSA level. Yeah. Great question. Thank you. Really it comes down to at the end of the day whether that expense is charged to one care or the hospitals one care has no other revenue stream essentially to generate. So we if that if the outcome were such that one care had to fully pay that that amount we would deplete our full amount of reserves and then it becomes a question of the one care provider network either to restore those reserves and continue operations or not. And I think it's better to have a prospective plan of here's exactly how we would manage the circumstance if we really did have to pay those advanced shared savings dollars back. How do we ensure that the ACO remains sustainable and viable and everybody knows the arrangement up front entering the performance here. Thanks. I think my last question but let me just take a quick look. Oh, the other question I had which is in part connected to thinking about the Medicaid global payment program development is. I wanted to confirm that there's still a prior authorization waiver for medic for practices that are participating in the Medicaid ACO program. We haven't heard about that recently I know there were some challenges initially in terms of the implementation and I'm just wondering sort of the status. We get some general terms on it that well through time there was a very specific prior authorization waiver eligible for participants in the Medicaid program. But one care and diva. I think everybody agrees it's better to have a single prior roth paradigm rather than having to say right this person subject to this prior roth requirement and this person subject. So Diva's done a lot of work to simplify and align and because we have such a high percentage of Medicaid membership attributed to the ACO. It makes it a little bit easier to get this uniform PA structure in place. So I very much appreciate Diva's work on this front. I think there's still some opportunity to figure out if there are other services or areas where we can be more efficient. But we're trying to move to a kind of a single paradigm where the same prior authorization waivers are universal. That's it for me. Thank you. I'll hop on. Thank you so much for the presentation. I think I'm going to start with I'm intrigued by the provider account abilities that were added in the 2024 contracts. And so I had a couple of questions around that since this is a new initiative there in these contracts and I'm wondering. So for example, citizenship, which is around the commitment to the values of one care. I'm wondering how will you monitor and measure that accountability? What does that mean? What does that look like? How do we know if we're good citizens or not? Not we but the provider network? How do you measure that and monitor that? So you're right. It is a tricky, tricky one to measure. Again, what we're trying to go for their member homes is creating some accountability to work with the ACO on this work. What we found often is there are folks that come to the table and want to participate, but then are not necessarily aligned in their approach outside of that table to what we're trying to do. So I don't know that we have a quantitative way to measure that, but we're just asking folks to come and extend trust and work with us on these programs and not take steps that run counter to what was agreed upon entry into the APM into one care as an ACO. So I don't know, Sarah, if you want to add to that or Carrie. Maybe you can give me an example of that. Something that you're trying to reduce incentive to do through this accountability of citizenship. What is something that has defied the values of one care that you don't have to give me specific names. Just like I'm trying to understand what is the behavior that you're trying to incentivize here through this accountability. Looks like Carrie has an example. Yeah. So first of all, yes, thank you. The values are collaboration, excellence, innovation, equity, communication and integrity. And so I think, yes, it's hard to measure those, but you know it when you see it. And it's on us to have conversations with people who are not joining with us in this work and exemplifying those values. And so it will probably fall on me to have those conversations. Once those things are identified, we are putting into writing how we will monitor this so people know and as best we can define it. It is an area that is hard to define, but we certainly want to address things that are not compliant with this when we identify them instead of just letting them ride like we may have done in the past. So if we sense that there's a member that's not collaborating, not coming to meetings, not communicating, not answering our emails, not giving us reports, we will have a conversation. Yeah. Those are all fair examples, Member Holmes. I'd say further, this isn't compulsory to be in the ACL. And the programs are working on we don't, they're not required. So it's challenging when we have somebody who's in the program, but as Kerry said, they're sort of half-heartedly in it and not coming to the meetings and not doing the things that we're asking them to do. And then further, if they're in public through an op-ed or other opportunities looking for opportunities to sort of discredit the work that the APM is trying to do, it's challenging to work with those folks because we're like, whoa, do you want to be in or not? You don't have to be in, but if you're in, we're expected to all of a sudden work together to get this done. It's a matter of trust, really, of like, how do we establish a bench line trust? So it was never intended to be punitive or to exclude folks. It's just saying, if we're in this together, let's be in this together. Got it. Okay. On the engagement, you know, accountability. So I'm interested in the, I looked through the, looked like in the contract, it said provider accountability's agreement. It suggests that all individuals within organizations performing ACO activities will be held accountable. So that sounded like it was at the individual, anybody in the individual level at an organization that's participating is going to be held accountable. Inclusive of the engagement accountability, which requires participation of 50% or more, you know, in these value based care meetings. But then I thought I heard Dr. Wolfman say it's at the tin level. So I'm wondering, for example, providers that are, you know, at the UVM Medical Center, which is a very large organization, many, many providers is the expectation that each individual boots on the ground provider in that organization is engaged in the ways in which one care hopes, or is it like, you know, what, what is the level of engagement, for example, at a large organization to satisfy this accountability? I'm happy to jump in there. I think we clarified this a little bit in the latest round of questions as well. I don't think, frankly, that it's realistic to expect small or large every individual to be in all of those sessions that Dr. Wolfman described. However, we want to make sure that within those organizations, they're identifying people, whether that be by initiative, by content expertise to participate in those settings. And so we're expecting them to identify who those representatives are. And we are looking for some consistency. It might be seeing the same person over and over in the quality space and perhaps a different person in the financial management space. And we are communicating that we are willing to help and support and create materials, but we need them to then pivot within their organizations and help share more about the focus of these initiatives. What we're doing, why we're doing it and how they can contribute. And so some of that responsibility is on us to help support that. And some of it's on the providers to organize around how to communicate with the middle organizations. And do you have a mechanism? Go ahead. Sorry. I was just saying, I think Sarah stated it well, it's really a two way street of us having consistent engagement. So when that engagement is lapsing, we're just looking to reestablish that so that we share the accountability for keeping information flowing, as well as just generally staying in tune with what's going on. Sometimes as you have some transience, you lose the thread and you lose that connection with an organization. Yeah, and I guess I'm just wondering, do you have a way to assess whether or not it is trickling down to the boots on the ground providers in these larger organizations? Because we've heard over time and certainly hearing from providers in larger organizations, there seems to be a disconnect in understanding all that OneCare is doing, different payment models, different initiatives. I'm just wondering, I really like this engagement accountability. But I'm just wondering how you're tracking and making sure that as you're increasing the conduit, at least between OneCare and somebody, key personnel in each organization. How then we're making sure that the information is traveling down to the boots on the ground provider who's working every day in the clinics. Yeah, it's a fair question. I can cite the example with UVM. I've worked really hard with Jessica Michela who leads high value care for the health network on that exact problem. And that's one of the ways that we're increasing our partnership with the PHSO to make sure that it gets down to the provider and clinic level across the organization. I don't know if Dr. Wolfman or Sarah want to comment on other organizations, but I agree with you. It is a concern of how we can make sure that it's filtering out through the entire organization, not just through those contact points that we have. I'll just add one key strategy that Dr. Wolfman described earlier is really about strengthening OneCare's relationship and coordination with the blueprint who have more feet on the ground capacity in some of those relationships. And so the more that we are doing our work collectively ahead of time to plan and align, the better off we are in helping those messages to permeate down through organizations and across teams. And so that's been a real focus of ours as we recognize that it probably doesn't make sense for OneCare to have those duplicative roles or services. One of the, in your narrative, you focused on or mentioned some of the network development challenges. And one of the examples that you gave was that for some institutions, organizations, providers, they felt like they could do better under Medicaid fee for service as an obstacle. So I'm just wondering if you could speak a little bit to that. It's a little more context. Yeah, I can take that one. So, as I mentioned, all these programs are voluntary and every organization is going to evaluate the opportunities under the ACO framework relative to going back to fee for service, so to speak. And it's tough. We always have a timing issue in that providers need to make commitments to these programs before we know our final terms. We haven't finally negotiated our targets with Medicaid and we don't know exactly what the AIPBP payment includes the population based payment for Medicare will be yet. So it represents a leap of faith from these providers to sign up for the program and, and frankly some trust in OneCare that will deliver some reasonable financial terms to them. So, you know, through time, sometimes there's differences in the analyses between the organizations and that's where we get together, share notes, make sure that we have sound data and are seeing the world the same. And sometimes we come right together in the line. Other times we have differences in our analyses and opinions on it. So that's a reference to a comment that we've heard from organizations in the network. And we just do our best to ensure that the process that we have with Medicaid is sound and that we deliver reasonable financial terms to these provider organizations as part of their sustainability. Yeah. And zooming the lens out a little bit, I think some of the uncertainty around the future of payment models in Vermont has caused some of that member homes and, you know, further and say it's beyond just us having signed our payer contracts. We haven't had our budget approved yet at that point. So there is a level of trust in kind of how the system is going to work, whether that's going to create the, you know, financial cover for them.  So it is a challenge from a timing perspective, as well as just an uncertainty perspective for some of our participants. Okay. I just wanted to talk a little bit about the performance incentive pool, which I know is designed to try and, you know, reward strong performance around meeting total cost of care targets and then avoidable ed visits. And I'm just curious your take on whether the the incentive is strong enough there. I noticed I think it was 2022 and if I have this data wrong, I think I found it in the submission. So if I have this wrong, please correct me, but it looked like in 2022, the Medicare shared savings amounted to about $49,000. And it was shared across seven HSAs in that performance incentive pool. Is that correct? Am I right on that? Because the follow up question is, then is that enough of an incentive figure $7,000 per HSA as a reward for strong performance? I guess I'm just curious if that's enough money to generate the types of, you know, changes that we'd like to see. Great question. Like, you know, the answer is, I'm not sure that it is enough money. This was designed to be a step towards reinstalling some HSA level accountability under the risk sharing model and resharing arrangement. And due to just uncertainty in the future of these arrangements, we've really kind of held consistent our risk model over time. But I think the concept is important and worth building on. This is something that we've discussed with our finance committee and board about how we've evolved that risk sharing model through time. And I do think that there's an opportunity to build in some HSA level accountability in a similar way that the performance incentive pool is designed to do, but in a more effective way where there's more dollars potentially available to HSAs that perform well. So this was a small step in that direction and, you know, going back and forth with our committees and our network, just the potential uncertainty of the future has kind of left us in a place where we're going to stay the course right now. But every year I bring a risk sharing discussion to the finance committee and talk with them about how we want to move forward. And there's some, there's some motivation to do that. And this is one of these age old questions that you've hit on, which is because of the statewide nature of one care, which is a little bit unique, how much do we put at the state totality level or bring down the HSA level. It's a challenge, but it's a fair question. Just about the mental health screening initiative, I think if I have this right, there were 92, right, 92 practices of the 117 that were eligible. Is that for the tier two payment, the screening only payment? Is that right? My follow up question really is what percentage we're doing tier three where they were kind of taking a step forward and either hiring additional mental health staff or partnering with a community organization. I'm trying to figure out what of the sounded like 92 we're doing the first step of screening. Is that right? Yeah, great question. There is some confusion here. So I appreciate you asking the tier two, tier three concept is for the CPR practices alone. We actually developed this kind of this concept first where tier two was just a commitment to the screening. Tier three was actually that integration of mental health supports into the primary care setting. The mental health screening initiative is available to everyone. And that's, that's essentially the tier two equivalent in the CPR program. Not the tier three. Okay, so there is not a, so. Okay, let me just ask this then in the CPR program. What percentage of the CPR practices did tier three? Is that an appropriate question? I'm trying to get a sense of how many. Okay, I don't, I don't have the exact data point, but I'm happy to feed it to you and somebody on my team was ascending to me. I'll gladly report it. Okay, that's fine. I think my part of my sense of these questions is screening is a great first steps. Totally appreciate the effort here. I think if we don't understand the problem, we're never going to solve the problem. We're never going to be able to start having the care that we know that our Vermonters need in the mental health realm. I guess one of my concerns is that we're going to screen many, many people who are going to have mental health conditions. And there's not going to be enough people to refer them to in, you know, the second stage of okay, we've identified a problem. And now there's a big long wait time and so that the additional payment to incentivize additional staffing seems really important to be able to make sure that we have a supply of providers that can now meet a greater identified need. So I was trying to unpack and understand how that incentive is working and if there's a big uptake in the additional staffing component. So maybe there's a better way to ask this question, but I'm really trying to understand how many practices are actually because of the incentive payment trying to hire and recruit mental health staff to meet what's going to be a growing need. Identified need. The need is there. Identified need. Is there any way of unpacking that from your data or this can be a follow up question. That's fine. I'm happy to talk with you some more about that later. Part of the incentives for this year include referral for a positive screen starting halfway through the year. We didn't specify what that referral had to be. It could be any kind of a referral, but addressing a positive screen and checking off that there was something done about a positive screen in 24 working with the blueprint. The blueprint expansion project does include a lot of money to upstaff. And so that's one of the reasons we want to partner with them so we can put all of our funding sort of in the same bucket for this effort. Our money that we contribute to this work in 24 may go probably won't go directly to upstaffing, but it will probably more likely go to enhancing it capability so that we can record the data. We got responses back from people this year that either their EHR does not include a module for recording this data and or it would take quite a bit of money to pay somebody to build the module in their EHR. So, you know, we spent 1.6 million on it this year. We need to find out what people did with that and hopefully they built their modules, which is what they told us so that going forward they can utilize it. But I agree with you. I think there is obviously we know we have a shortage in mental health care provision and I think one other area we need to incorporate exploring our digital solutions. Yeah, I know it's a work in progress. Everybody's talking about it thinking about it. Just wondering. Yeah. All right. So my last question I think I want to give everybody else enough time to ask their great questions is on that slide 25 that Sawyer mentioned, which had the percentage of the subpopulations that are under care management. And to be fair, like I when I first saw it, I thought, oh, 10% of those with high total costs of care are being managed and I thought that seemed low. But I recognize that, you know, there are many things that I don't understand about how difficult that might be to identify and then manage the care of some of these at risk populations. So I'm wondering, do you have goals for each of those subpopulations? Like what would be, I mean, obviously optimal as 100, but what is a reasonable feasible goal for us to imagine attaining in the near future for these subpopulations is, you know, 10% for total cost high total cost of care folks how far off what's feasible and reasonable to assume is that I'm happy to go first and Sarah you might have some more information. I've asked the same question of the staff. What are our targets? How do we set targets? Are there national benchmark targets for these populations of focus? And to my knowledge, there are not set targets. We don't have a basis. Our expectation is that these rates will continue to increase. Like you said, 100% is wonderful. But if we can just keep seeing them go up, I think that's important. The other thing to note here is there's probably overlap, you know, in these groups, obviously. So that also skews the data. And just one quick follow up question. What are the obstacles? I mean, as you see it just logistically and identifying and then putting together a care management team for these subpopulations. What are all the places in the pipeline where it can fall apart to manage this care of these identified subpopulations? Well, the two that rise to the top for me are not enough people to perform care management. And the second barrier really is that a lot of patients in these groups don't choose to participate or they come and go, come and go. So those are some of the top barriers. And then thirdly, we need good data. You know, the data needs to be have integrity. And I think moving to the Arcadia platform is going to enhance that. Great. Thank you so much. I appreciate all your answers. Jesse, are you all done? Great. Okay, I'll step in next. Thanks so much for the presentation. I really appreciated actually both reading through the budget and the presentation. It's super helpful to understand all the various components of the organization. Clearly a lot of really great programs that have been going on that have been refined over time. I have a few questions sort of on some specifics and then some sort of bigger kind of level questions kind of broader view. One is Dr. Wolfman on slide 28. When I looked at that slide, I had some questions about, I was actually going to ask you a question about the diabetes control measure. But since that's being retired, I guess we could sort of say supplement in a blood pressure control measure and the concept of equity. And if there's any concern or how to mitigate providers trying to shed or not attract patients that may be either have, I was going to ask, high A1Cs, but who are people who are difficult to get into the clinic for blood pressure management due to transportation issues, all the various elements of social risk and how we can create incentives that improve patient care but avoid the pitfalls of building in equity issues and shedding patients who are challenging. That is a wonderful question. I don't have the answer about how to help providers or ensure that providers don't do that. And it isn't something we've discussed a lot at one care as far as tackling taking on that responsibility. Very good question that we can think about more. We have not really worked on that yet, but I can see why this slide made you think of that. It is an area of equity that we need to focus in on. Okay. Yeah, thanks. Dr. Raman, I just say you're raising a fundamental question as we evolve away from fee-for-service methodologies that go toward the panel management that we need to think about that, the perverse incentives that that might cause. So it's a good question and something we can think more about, but thank you for it. Yeah, I was actually going to ask a kind of a broader question on that line is to, when we think about giving like prospective payments or population-based payments, how to take these factors involved in developing the plans. How do we measure and mitigate the potential risk of sort of selective rationing, I guess, in a sense? Yeah, and I think it's an evolution of the current sort of fraud-waste abuse ways that we look at the payment model and evolve that towards, again, identification, prevention, mitigation of all those sort of, you know, perverse incentives and possible negatives that come along with evolving the payment model away from fee-for-service. It's still a work in progress for us. It's something we do think about, though. Have you been able to figure out any ways to build that into a payment model at all at this point or not yet? Oh, I can take that one. Yes, we have. So particularly in our Medicaid fixed payment region, which is unreconciled fee-for-service, we segment that payment into two different parts. One piece is a component for local HSA care going to what we call the home hospital. So that would be, you know, burling in HSA residents going to UVM Medical Center. There is a separate component that every hospital has for care that comes in from other communities. So we're monitoring through time how much, if there's any change in care delivery patterns, that would suggest that a hospital is starting to refer care out to a neighboring hospital to potentially benefit under a fixed payment arrangement. We also built in kind of automatic adjusters to that. So if we did see something like that happen through our reconciliation internally at the end of the year, we protect a hospital who received more patients from out of county. And we actually charge that to the hospital that moved that care out. So we have some dynamic ways to make sure that the both the hospitals are protected and then at large we're monitoring those patterns and ensuring the funds are used appropriately. Okay, but I'm sorry. And then did I miss it when you were discussing it that do you have a mechanism then to track to see if for some reason there's decreasing amounts of care provided to a Medicaid population within a specific HSA? Yep. So as part of our monitoring, we look at every hospital's fixed payment component for their local HSA lives. And if we were to see a stark drop in how much care they're delivering, that would be a flag that we want to look into and speak with the hospital to understand exactly what's going on. Okay, but but a subtle trend could probably could slip slip through there. I guess part of this also as I was looking at the Nordk report which is sort of the other big area of questions that I was going to ask you about today. And I could just sort of jump jump into that conceptually which is you know one of the things that that a lot of credit's been sort of taken for is decreasing hospital admissions within the Nordk report and I think we intuitively think okay well this is great that lowers cost of care, but do we know whether or not that decreasing hospital admissions is actually better care or is could there be an equity distribution problem within the way the hospital admissions are decreased? And so I guess I was just trying to figure out if that's something that within the current data platform you're able to evaluate and if you have and if you know what's going on there. It's a good question. You know as Abe said whenever we evolve this the way our industry healthcare industry works is something new there's a whole new set of things to look out for and I think you're raising some really good ones here today. Specifically, no, we don't have an exact analysis that says the reduced hospital care was better for patients. But I will say all these programs are designed to longitudinally for multi years performance. And if any provider thought that just in a one year span kind of moving care out of the hospital which wasn't the best thing for the patients is a good strategy. That'll come home to roost in future years so there's really these models do incentivize the right behaviors for people over a long span and I do worry about ACOs that operate in a more flash in the pan kind of way. So you can capture shared savings but I'm not sure that's better healthcare. So we try to set these structures that establish the right framework for a long range improvement in evolution of our healthcare system. I guess what you know I think this is that complicated problem right so fee for service incentivizes, you know, volume, and you know the problems with back in the day have capitated payments and seem to incentivize rationing we're hoping these sort of more flexible population payments don't do that but when we look at decrease specialty care access decrease acute care hospital stays without having the really robust measurement of the potential downside of that in in established I think it's hard to say and so when I see these things it's okay so great like this could be really good this could be really good that we didn't admit a bunch of people to the hospital that didn't need to be admitted and you know as as, as you know I'm an emergency provider this is over my career is really changed we admit far fewer patients to the hospitals were way better outpatient diagnostic algorithms were made better an emergency department diagnostic algorithms and way better outpatient treatments. But to see a decrease like this compare, compared to the comparison group does lead the question to me of, of what is the decrease due to and I don't know if you've had any chance to pop on to any of the all over why I'm in listening sessions or my personal experience and seems to be a shared experience throughout the state is that hospitals have been really full. And so is the decrease admission, due to lack of capacity and access, or is the decrease admission due to sort of the positive things. And, and so I, to me when I read this report, it, it isn't necessarily a positive report it's a, hmm this brings up some really interesting things. There's a lot to unpack on whether or not reducing acute hospital admissions is a good thing or a bad thing. But yeah, it's fair. Dr. Merman, I think they also wanted to just point out some work that Dr. Wolfman's leading, which is the unique role that a CEO is play when it comes to health equity and really improving. Well, identifying opportunities to improve those who are suffering from inequities and disparities in developing strategies and population health tools that we can apply to address those disparities we identify them. You know, specifically, I think some of the work recently carries done with another physician that works with us, has it been around looking at cancer screening rates for the Medicare cohort and determining if there are disparities amongst different groups for that. So it's getting to some of the things you're talking about. I'll let Carrie add to that a little bit, but I agree there's work definitely to be done here. Some of it first is identifying what data we have, how quality, how much quality there is that data and how we can take action from it. I agree. There is a lot. We could talk about this for a long time and I would, I would like to have more conversations about this. I think there's a lot more we need to dig into. We're a little bit right in a transition zone going on to the Arcadia platform, but hoping when I get to see the data that we can get out of that system, we will be making plans for looking at even more disparities than we've been able to so far. Great. Let's chat more. I reviewed this piece in the digger. There's a couple pieces that you guys had put in the digger. It looked like sort of a kind of a paid spotlight piece. The one is one care of Vermont is successfully driving down health care costs talking about the North report and I just want to sort of try to unpack this a little bit. So the North report shows reduced spending of Medicare spending for patients in one care, I believe. Is that correct? Yes, but relative to a comparison group. So it's kind of a relativity model rather than just a straight up. Here's pre and post. Yes, relative to the 26 counties that were the comparison group is a little challenging because the comparison. A little challenging. No, it's not. Yeah, it's these things are always hard to do. I guess the comparison group is challenging because it doesn't. It's not super clear to me when I look through the methods of the of how the comparison group is relates to our group, but it sounds like they tried to match them as best they could. And I appreciate their methodology there. So where does that savings go? Who gets the savings? Well, that that report is more of a conceptual evaluation of how Vermont is doing relative to other comparable areas in the in the country. So just because the report had some positive results doesn't necessarily mean there are savings captured. However, under our programs, we have earned shared savings and that gets reinvested in the provider community. And I hope continues to make this work sustainable and kind of a virtuous cycle through time. Okay, so in that, in that piece of the digger it said CMS analysis underscore to one carries achievements demonstrating reduction of over $1,700 in Medicare spending per beneficiary along with your hospitalizations ed visits readmissions and over the four year study period so that's $1,700 per Medicare beneficiary reduction. That's where is that $1,700 Medicare had saved that $1,700 per beneficiary relative to the comparison group. I think what's challenging about that North report is that that relatively concept in that it's entirely possible that, you know, we've done good work. We beat our financial targets. I'm really proud of those results. And it's just hard to know because this is benchmarked against another area so we might have had some savings, but it might not actually be that total because that's a relativity to other areas and if other areas are seeing more explosive costs so it makes Vermont and all the work going on in Vermont look better. And if that's difficult to quantify when it comes home like I'm not sure we have the full information and data nor might be a good resource to ask this question to but I'm not sure we have the information Vermont to say that of the savings quote in the North report like that's exactly what was saved here. I'm not totally sure that I mean Dr. I think it might be advisable for the board to invite nor to come back to address the board as you've had other speakers come I think I think that's been done in the past I mean we're really brought in by CMI is an independent third party to evaluate the success of the APM so I might be helpful to hear directly from them. I think that'd be great. I'm just going off of more of what the press release was on your your website discussing about I mean another quote is with over 5000 provider statewide partnering with one care the research resources that contributed to higher quality care and substantial savings for more than 200000 Vermonters and so I'm just trying to figure out when you say there's substantial savings for 200000 Vermonters in this public forum what is what is that substantial savings so I'm trying to figure out that those actual savings those dollars who saved the money to 200000 Vermonters save money on lower copays to the state save money on lower health care expenditure by rate payers or Medicaid Medicare save money by paying Vermont less less for the care you know deliver where is the it's a very glowing a very glowing piece about how great the snorkelport shows how wonderful one care isn't saving money and I'm trying to try and figure out what does this actually mean what what money and who's saving it. So it's it's Medicare expected expenditures over time versus that benchmark population versus what actually occurred. And so if you're asking those that accrues back to Medicare accrues to Vermonters I mean that I think the answer is pretty self evident that that's designed to reduce the burden that Medicare has on a per beneficiary basis. Okay so it would be a little misleading to say that for 200000 Vermonters had savings during this period of time from the nork report. I'm not sure how. Well I'm just quoting what you had said there's a substantial savings for more than 200000 Vermonters. I'm not sure how it's misleading. I mean we're literally taking out of what a third party. It's dead in their report. What. Okay so if the if the third party says in the report you don't you don't I mean this is a report for Medicare. So Medicare save this money. That's different than 200000 Vermonters saving this money and then publicizing that I think they're just different things. I think what I'm trying to say is I think the waters get very muddied when you're taking a lot of credit for things that now you're saying well we don't even we didn't even substantiate this report. I mean it's just you know as a regulator it's just challenging as a remonder it's challenging to see that okay one care saving thousands of dollars for Vermonters and now you're saying well well we're not sure what that money is. Maybe that's money that Medicare is saving. So is that shared savings that went back to the hospitals then. I think Mr. Boris talked about the difference between the model that we're in that's designed that was agreed to by the state versus the way that it's evaluated by this third party evaluator. Okay. Would it be fair to say looking at the third party evaluation the North report as you read it that Vermonters didn't save money as evidenced by the North report but Medicare saved money as evidenced by the North report. I don't think we ever implied that Vermonters were saving money. I think we were implying we're trying to reduce the total cost of care to care for Vermonters. So if that was misleading to you in some way I apologize but that wasn't our intent. We were looking at a directional analysis that was provided by a third party that CMI hired to evaluate the success of the all pair model of which we're all part of. Okay. I just think that you know one of the challenges that we have on the board is we have to look at the other component of spending which is commercial spending. And so when we say OK one care is saving all of this money but yet we're seeing commercial spending going up up up. You know as the board we're trying to balance those things. So when you're promoting the idea that Vermonters are saving a whole lot of money through the North report findings and the North reports findings don't actually save the Vermonters are saving money. Higher quality care and substantial savings for more than 200,000 from others. I'm just quoting what you what you have on your press release. I think you're I'm not trying to be argumentative. I just think you're reading into a meeting that's not there. So if the wording is not clear I apologize. But again this is a report that's requested by CMI to evaluate the APM which the state is the party to. So I guess yes that you bring it that nor can talk about the findings. But it feels like you're trying to imply that we're being disingenuous and I don't think that was our intent at all. I think I am actually after saying this because as I read this it's clear to me that you were talking about how great one care is it driving down health care costs and how this is great for Vermonters. But yet at the same time now you're saying well the North report says the Medicare saving money and you did not intend to imply the Vermonters are saving money here. I just I'm trying to follow your logic. Dr. Merman I'm not trying to be disrespectful. I just are intent in totality. We're trying to do here is reduce total cost of care expense. Whether you frame that as saving money for Vermonters. I don't understand that but we're trying to reduce the total cost of care for a population. And the report said that we did that. I agree that the report said the total cost of care went down. And it implies that you did that. Although interestingly and even more complicated with this sort of the whole flip side of this thing is the total cost of care went down for unattributed patients more than attributed patients. And I'm trying to that was sort of another line of trying to understand this is why do you think that's the case. This is another thing that I think is a misconception. I read a op-ed about this. I think it's really important that the board bring in North to explain the methodology embedded within that whole statewide number is what happened with one care. And let's be honest providers look at a whole panel. They don't know exactly who's attributed or not as is attributed. So the things that we're doing at one do have an impact across a broader population than just the single population that's attributed to the SEO. I appreciate that concept. I think I'm going to pass off to whoever's next. I do really I'm really impressed with so many of the programs that were outlined today. I think that this complicated messaging about all this financial savings I think makes it complicated to look at the overall performance but I'm really impressed with so many of the individual programs that you outlined today. Thank you. I appreciate that. And again our intent is not to be combative. Just try and answer the questions as best I can. It's 12 30. So why don't we take a break so people can get a little bit of lunch. We're scheduled to go till three. I think I'm hopeful that we won't go that long. So why don't we take we take 40 minutes and I got to find a place to eat. So we'll come back at 110.