Okay, I see it's now one o'clock. So I'll call to order the Green Mountain Care Boards meeting of December 14th, 2022. We have two primary agenda items today and that is the deliberations relating to one care of Vermont's fiscal year 23 budget and also the HIE plan. Is the sound on? I'm sorry, can you hear me? Yeah, we can hear you. I'll turn it to Ms. Barrett for the executive director's report. Thank you, Mr. Chair. I want to announce that we've added a board meeting to our schedule for next Monday, December 19th at 9.30 a.m. At that meeting, the Green Mountain Care Board staff will present the 2023 Medicare benchmark proposal to the board and we've also noticed a potential vote on that proposal. And I will remind you of a couple of ongoing public comments. First point. Is the sound on? Yes, the sound is on, Ham. Is that Ham? Okay, I will just wrap this up and maybe somebody could reach out to Mr. Davis and help them with some of the audio. Kristen, maybe you could do that. So the ongoing public comment periods first, One Care Vermont, you're gonna hear more about that today as Chair Foster mentioned, that we would encourage folks to supply public comment on the FY23 One Care Vermont budget before the board votes on that, which is scheduled for next Wednesday, December 21st. And last, we have an ongoing public comment period on the next potential all-payer model with the federal government. As I've mentioned before, a agency of human services and the governor's office are leading these negotiations. So any comments we receive, we do share with them so that can help inform their negotiations.  Thank you. Thank you very much. So we'll take up, we have two board meeting minutes to take up. First is December 5th, 2022. Is there any board comment or discussion to those board minutes? I'll move approval. Is there a second? I'll second. All those in favor, please say aye. Aye. Aye. Aye. And the vote is unanimous, the minutes are approved. Next, we'll turn to December 7th, 2022. Is there any board discussion or comment? Is there a motion? I'll move approval. Second. All those in favor? Aye. Aye. Aye. The board minutes are unanimously approved from December 7th. And I think the first item on our agenda is the health information plan. Is that right, Ms. Barrett? Okay. And we'll turn it over to Kate O'Neill. Kate, how are you? Nice to see you. Thank you. Thanks to see you. Thank you, Chair Foster, members of the board. Thank you for the opportunity. I'm going to share my screen and pull up some slides for you. I'm going to just walk through a brief set of slides here to share a staff review of the 2022 comprehensive five-year update to the health information exchange strategic plan as well as the 2023 connectivity criteria. So again, I'm Kate O'Neill, Director of Data Analytics here at the board. And I'll get started. Just a quick process reminder and timeline. On October 31st, AHS submitted the HIE plan and connectivity criteria to the Green Mountain Care Board. And on November 16th, AHS as well as Vidal presented on the HIE plan and the connectivity criteria. The board requested changes to the HIE plan at that time. On December 9th, AHS resubmitted the HIE plan. And that is posted to our website as well as a part of the meeting materials for today. And here we are today, December 14th with staff recommendation to the board on the HIE plan and the connectivity criteria. And we have one to vote for today. Just another note, we had a special public comment period from November 3rd through December 2nd. So I'm going to start with the recommendations and we recommend one that the board approve the 2022-2027 HIE strategic plan. And two that the board approve the connectivity criteria for 2023. So the way we did our review was to use eight criteria or questions. And so for each we hear, I will share a summary of like a broad description or a sample of evidence as found in the HIE plan. It's not an exhaustive inventory, but it speaks to each of these criteria and questions that we use to do the review. So number one is the HIE plan consistent with HIT plan requirements of state legislation and does the strategic vision in the five year comprehensive update align with the intent of the plan as described. We note that the HIE plan statute outlines a variety of features that the HIE plan must address. And AHS is required to revise the plan annually with a comprehensive update every five years. So this is the five year update, but there will be annual updates each year throughout this next five years. So this slide, slide six, is a summary of the HIT plan requirements as outlined in 18 VSA 93.51. And while I'm not going to go through each one of these, you have the slides. What I wanna share here is that we do see evidence that these requirements are exhibited in the HIE plan. So it's addressed through goals in some of the cases it's addressed in terms of understanding the need for plans for the future, such as future funding options and strategic solutions to streamline, increase efficiency and reduce redundancy and that sort of thing. The plan does address these requirements. The second question is, is the HIE plan consistent with the principles for healthcare reform? And we say yes, the plan broadly aligns with a variety of ways in a variety of ways with the principles of healthcare reform ensuring access to care, containing costs and sustainable financing, transparency, efficient and effective or efficient and accountable systems, preserving primary care and the patient clinician relationship. Those are broadly the healthcare reform goals and the VHI goals or the goals that are outlined in the HIE plan do support improvements in healthcare delivery, health outcomes, enriched healthcare data collection and analysis. So the third question is, is the HIE plan consistent with other relevant legislation? And this year Act 167 was passed and section four requires the continuation of work to create one health record for each person in Vermont and also requires a data integration strategy in the year 2023. So the HIE strategic plan outlines a strategy to merge and consolidate claims data in V-Cures, the claims database with clinical data in the HIE. And the plan does speak to efforts toward these goals and the Green Mountain Care Board staff and AHS staff have been and will continue to work together to identify strategic solution options for meaningful and secure data integration of these data assets. The fourth question that we looked at was, does the HIE plan incorporate national best practices and expertise as well as feedback from Vermonters, so stakeholders and in terms of national best practice, the plan does incorporate best practices around the development of health data utilities and addresses building on previous work around interoperability. Related to health data utilities, we know that this is an emerging concept across the nation and many states are working toward this endeavor, Vermont included and there's much to learn in terms of overall strategic design and Vermont is certainly is not alone in this effort. In terms of stakeholders, certain agency and provider stakeholders are members of the HIE Steering Committee and work is underway as described in the plan to expand stakeholder reach as well as to incorporate stakeholders in the development of the data governance structure for the unified health data space. An expanded range of stakeholders was involved in the interview process with AHS's vendor, which is helping to develop the data strategy which did inform the development of this plan and that vendor is still working to support the development of the data strategy. So to what degree are privacy concerns and privacy protections addressed? The plan includes descriptions of current and planned for privacy and security protections including certifications and practices, not an exhaustive list as I said, but some examples are the VHIE has adopted NIST or NIST cybersecurity framework to manage its IT security risk. There is a plan to establish a data governance council they do speak to including a privacy attorney or a privacy expert as part of that council. The HIE Steering Committee will request representation from patient privacy advocates and IT privacy experts and the VHIE project management process includes provisions for things like privacy, security, consent rules to be gathered, included, implemented and validated and that is a standard practice. So the sixth question that we asked is how does the plan address and plan for increased capacity needs as the strategic vision expands? I mean, the plan recognizes that the VHIE will continue to require enhancements to build on core technology components already in place. They provide examples such as building data marts, analytics and optimizing data usability, making data more usable. So the plan describes Vermont's current health information exchange structure as well as planned enhancements. And also AHS in consultation with the HIE Steering Committee is responsible for administering the plan and that includes designating vital to operate the health information exchange and to oversee the implementation of HIE development and its standards and its protocols, including the manner in which it's operated. The seventh question that we used to evaluate the plan are proposed strategies within the plan, feasible, realistic and achievable during the timeframe covered by this plan. The plan does include descriptions of the use of feasibility assessments for the envisioned VHIE enhancements and the plan also describes the use of APDs, Advanced Planning Documents, which is a requirement of CMS for federally funded IT system projects and Advanced Planning Documents describe the need for feasibility of and projected costs and benefits of an information system or a systems acquisition. So those tools are in place to help with gauging and managing the feasibility and the realistic vision of the next five years. And I would also take a moment to remind you that while this is the comprehensive five-year update, the HIE plan is updated every year and that of course would continue as an annual practice. And so each year there will be an opportunity to look at feasibility, realisticness of the vision. And then the eighth and final question that we used was how aligned is the plan with current legal and technical constraints and considerations? And legal considerations are described through the plan in the context of HIPAA, business associate agreements and state and federal privacy laws. And technical considerations are addressed throughout the plan in the descriptions of the capabilities of the technical infrastructure as well as the enhancements that are planned for the future to ensure sustainability and scalability over the next few years. And these are a variety of components where technical capabilities are understood to be either maintained or enhanced for the future such as ease of use, bi-directionality of data, data matching and the like. So that was our review. We did only receive one written public comment on the HIE plan and that was from a member of the Green Mountain Care Boards General Advisory Committee. We talked about that at the last presentation of the HIE plan and that was related to the need for statewide data sharing among facilities. There was no other written public comment. So I don't have any more related to that to share. So that's the HIE plan. And then part of the HIE plan which is kind of an addendum to the HIE plan is the connectivity criteria that was presented to you in November. And so our review of that is are the proposed connectivity criteria in alignment with goals and will they support implementation of the HIE plan and achievement of the state's health reform goals? And the answer is yes, this year's connectivity criteria remain aligned with goals and are designed to support the increased availability of data, high quality data. And are the proposed connectivity criteria sufficiently clear to be operationalized by the state of Vermont and healthcare provider organizations? Yes, we think so. And in fact, these criteria were developed to expand provider's ability to submit and receive data from the VHI. And in September of 2022, so just this past September, the HIE Steering Committee approved the recommendation that the criteria remain unchanged for 2023 from that of 2022. So just a quick reminder of board duties. There are three pieces of relevant legislation. The first is the Green Mountain Care Board shall approve, reject or request modifications to the plan within 45 days. And we are within that 45 day window but we're right up against it. And the board shall review and approve the plan pursuant to section 9351 just to ensure that the infrastructure is in place to enable the state to achieve the healthcare reform principles. And the board shall review and approve the connectivity criteria that are for the healthcare providers and healthcare facilities to maintain connectivity to the VHI. And just a reminder also that the HIE plan requirements are in statute that the HIE plan must be revised annually and comprehensively every five years and include implementation of electronic. Did you, am I still sharing my screen? Yes. Yep, we can see it. Okay, it looked like to me it looked like someone took control. So these are the requirements of the HIE strategic plan in statute. And then again, the requirements of the connectivity criteria in statute. So this is a repeat slide but my suggestion recommendation here is that when you vote that you vote to don't think I'm sharing anymore but vote to approve the HIE plan and vote to approve the connectivity criteria. And that is it for me. I'll turn it back over to you, Chair Foster and I know AHS is here today to help me with any questions that you have. Thank you very much, Ms. O'Neill. And to the AHS team, thank you very much for working with us. You know, we were in a tight timeframe and you guys did a really great job. So I wanted to recognize that and Ms. O'Neill and her team as well. This is a big lift and I thought it went really smoothly. So thank you all. Ms. O'Neill, was there? I guess I was curious if there was a motion for the board to consider whether or not to make. Do you mean did I prepare a motion for you to consider? I think on that, I didn't make a slide for that but the motion would be to approve the HIE strategic plan five year comprehensive update. There's two votes really because there's that and then also a motion to approve the connectivity criteria for 2023. I can handle the motions if you'd like, Chair Foster. That'd be wonderful. Thank you, Ms. Lynch. Shall I proceed with the motion or would you prefer to do discussion first? Let's do discussion first, of course. I thought there was a slide on it. That's my mistake. We'll take any board discussion questions or comment and feel free to just speak up as you see fit if you have questions or comments. I can start. I just want to say, I really appreciate the staff, Kate, you and others looking over this with such careful eyes and very much appreciate AHSs, the time and effort they took to incorporate many of our staff and board recommendations and adjustments to the plan. And at this point, I've read it over, I really like the revisions and I would support the plan and the connectivity criteria. So thank you very much. Appreciate it all. This is Tom likewise. I want to thank Kate and the staff for all the work in creating such a clear review with recommendations for us and the AHS staff being so responsive to our questions and comments that we made after the first time. I'm fully prepared to vote in favor of this. I think the plan does not lack for ambition. There's a lot that it's trying to do, but as I said in the written comments to AHS, I really hope that as a group, and it seemed when we met with them, it seemed like this was happening, that they really also try to drill down to providing useful information to providers right away. Things like how many patients do I have that have diabetes? How many have an A1C level that suggests their condition is not being well-controlled? How many haven't been seen in six months? How many end up in the ED? How many end up admitted? Those things are all easy to calculate. It's not a network analysis. It's not regression analysis, it's division, but it's really difficult to gather that information from existing sources. It can be done and a lot of organizations who work on this try to do it in one clinic first, then move to another clinic, then another clinic, then the whole organization. It's a very step-by-step kind of methodical thing, no grand vision. And so I hope for the state that we keep our eye on that too, and not just the grand idea. So good job, Kate, thank you again. I don't really have any questions or comments. I just echo thanks as everyone else has already. Same for me, I really appreciate it. And is there any healthcare advocate question or comment? Nothing from us, Chair Foster, similar sentiments as echoed by members of the board. Thanks a lot. Ms. Lange, if you have a motion, I think that would be an appropriate time. Perfect. So I move that we approve that HIE strategic plan as resubmitted on December, hold on just one moment, I should have pulled up the calendar on December 9th. Second. And all those in favor, please say aye. Aye. Aye. Aye. Aye. And it is unanimous and the motion carries. Ms. Lange, do you have any other motions? I do. I would also move that we approve the connectivity criteria as submitted. And I'll second it. All those in favor, please say aye. Aye. Aye. Aye. And the motion also carries unanimously. Thank you all very much, we appreciate it. Our next agenda item is the one care fiscal year 2023 budget and we have our ACO team prepared today to walk us through some recommendations and to engage board discussion. I'll lay out a little bit of how we're going to handle this procedurally. We do have a time, a hard time stop today because some board members need to travel for board work and have flights and staff. And so what we'll do is we'll go through and Ms. Melamed will walk us through staff recommendations. If any board members have any additional proposed recommendations, they can add them to the list at the end of the topic. We will then take up board commented discussion on those suggestions within a topic. And at the end of that, we will turn to healthcare advocate questions and comment. And then at the conclusion of all that, we will go to public comment. And with that, I'll turn it over to Ms. Melamed and Ms. Kinsler. Thank you guys very much. Great. Thank you, Mr. Chair, members of the board and the public. My name is Marissa Melamed, Associate Director for Health Systems Policy with the board. And I'm joined by Sarah Kinsler and Rush McCracken and other members of the team who are available. But Sarah and I will walk you through the slides to support today's deliberation. I'm gonna get those shared. Give me a minute. Are you able to see the slides? The agenda today, we're going to review public comment, received the date, review with you the decision before the board, as well as any relevant or updated analysis that was as was presented last week. And then we will help to facilitate a discussion of the staff recommendation and any additional board proposals. So I'm going to present each section recommendations and then pause for board discussion on that section so we can keep the discussion focused. And we'll hold a public comment until the end. So first we've received four additional comments since last week, 23 comments in total. In general, they fall into the categories that we were discussed last week around various values that OneCare brings and some concerns related to OneCare's operations as well. We've received an additional letter from OneCare expressing concern about one of our particular requirements around the Medicare advanced shared savings or sorry, recommended requirements around one of the risk delegation for the Medicare advanced shared savings which we'll discuss today. And all of public comments are available on our website if people would like to review them. So the decision before the board, we're going to discuss certification eligibility verification first, that process works a little bit differently than the budget. And then we'll move on to decisions around the FY23 budget. So on certification eligibility verification, OneCare remains certified unless and until its certification is limited, suspended or revoked by the board. We review it annually and the certification remains unless there are issues that need to be corrected. What we're recommending is deferring the eligible ability verification discussion until after the start of the new budget year to address some areas that are still under review. We often try to align these two and resolve them by the end of the year but this is not required to be resolved by the end of the year. And there are still some issues under review that I know board members like to discuss. And for time's sake, we would like to continue that discussion in the new year. Those areas include the executive compensation guidance that was issued by the board in 21 around that the ACO must structure its executive compensation to achieve specific and measurable goals that support the ACO's efforts to reduce cost growth or improve quality. The discussion around whether that criteria has been satisfied is a discussion we wanna continue having. As well as the component of the data analytics transitions that we wanna continue discussing. We want to continue that discussion in the new year. So we're gonna hold sort of a conclusion to this year's certification eligibility verification until we've been able to have that review and satisfy discussion around the executive compensation compliance with that guidance. So the recommended approach here is again, the GMCB does not need to vote in order to continue one care certification but action would be needed if the board concludes that one care no longer meets the requirements to be eligible for certification. And then in that case, the board would provide notice to the ACO and opportunity to respond before requiring corrective action. What I'm saying essentially is that you do not need to decide number two today or next week. You do not need to decide if you feel there no longer meet those requirements at this time because we can take the time that we need to make that decision. The review of the data analytics transition, and this is the exact slide that Russ presented last week. This is our recommended approach that the rule allows the board to use any and all powers granted to it by law to monitor the ACO's performance or operations or to investigate an ACO's compliance with the requirements of this rule. These reviews may be performed at any time. So again, a conclusion to this does not need to be made before the end of the year or prior to a vote. So we are recommending that we continue this review outside of the budget process and into the new year so that your questions can be fully answered through a more in-depth review. Okay, so I think that, so I wanna pause there and see if there are any questions about certification eligibility verification, annual review specifically. Do you need any clarifications on this process? Russ or I wanna help make sure that that's clear before we move on to the budget review. I have none, Marissa, but before we go to the budget review, I wouldn't mind reminding the public of the relevant statutory factors. And I can walk through that if that's helpful. If there's no other board questions on this slide, I can do that now if that works. Okay. I'll do that now then. So in terms of the budget, just for the public and just to refresh the board's recollection, which I'm sure they don't need, but when considering the budget, we have a record before us that includes not only one CARES budget submission, but also information learned from the hearing that was conducted on November 9th, 2022, and would also include, of course, OCV, one CARES written responses to board questions and public comment. And in evaluating the budget, board members are directed to review and consider the statutory factors that are set forth at 18 VSA 9382B1A through P. Relevant Board Guidance, the requirements of the all-pair model agreement and Green Mountain Care Board rule 5.4. And it's one CARE Vermont's burden to justify its proposed budget to the board. And the board has significant discretion in evaluating the relevant factors in determining whether or not one CARE has satisfied its burden to justify its budget. And that I'll turn it back to you, Ms. Melmed. Okay, thank you. So thank you for that summary. Here's just the opening language from 18 VSA 9382. Decision before the board is that there is a review, modification or approval of the budget of ACOs, like one CARE. So the decision that we're discussing is, do you approve the budget as submitted or do you modify the budget? And the budget guidance and the submission and the questions and the hearing are designed to collect the information that is required under the budget review. So that information is what we have on the record to help you make your decision. So we're gonna move into a deliberation of each area. These are the key areas of review that we went over last week. And for the first one, I'm gonna turn it over to Sarah Kinzler to walk you through. Thank you, Marissa. Can folks hear me? Yeah. Okay, great, thank you. Sorry, I can't quite see the screen and the slides at the same time. So the first area for deliberation is total cost of care and to trend rates. Our recommendation has not changed last week. So I'll just briefly restate. The recommended staff approach is to require one CARE to implement the benchmark trend rates for their payer contracts in alignment with our Medicare benchmark decision, which will be before you on Monday. The Medicaid advisory rate case and for commercial contracts in alignment with our rate, the rate review decisions. One minor language here, language change here to strengthen that sub bullet to be a requirement. And this is a new, this would be a new requirement to kind of allow us to collect additional data to better understand what one CARE has access to from the commercials and setting those rates. So that's total cost of care and trend rates. Is there discussion or question? All right, hearing none, I will move on to payer programs and risk model. So most of these recommended approaches also have not changed. The first is to require one CARE to engage in payer programs that are scale qualifying under the all payer model agreement, unless there is a good reason that they should not be and to help us understand why there are areas of misalignment if they exist and to require continued reporting on those programs. The second is to work with Medicare Advantage plans operating in Vermont over the next two years, especially focused on those Vermont based plans offered by Blue Cross and by UVM and in conjunction with MVP to develop scale target qualifying programs. Third is to implement the risk model as described in the budget with the exception of areas in which we may instruct one CARE to do otherwise and to notify us of any changes. And then finally, new requirement as stated last week to require one CARE to hold the risk for the Medicare advanced shared savings that those blueprint and SASH funds rather than delegating that to the network. As Marissa mentioned in her earlier remarks, that is a topic on which we received a letter, some public comment from one CARE themselves. So I thought I would just offer a few comments on why we made this recommendation and to describe a little bit more why we think that this is a valid approach. So first of all, as discussed last week, this funding is really meant to be an investment in Vermont healthcare providers not as risk to be held by providers. And we think that moving this risk from delegation to one CARE's network up to the ACO level can also help one CARE grow in their capacity to take on more risk and to offer more complex payment models in the future. For example, having some of larger reserves could allow one CARE to develop asymmetric risk arrangements for different types of providers which could help them to broaden their network or make payment models that are appropriate for various provider types. This is quite common among other ACOs and we think this is a potential first step in that direction. One CARE's letter raises concerns about potential liabilities and the ability to pay that money back in kind of a worst case scenario where they were required to return full amount of that risk. Our step analysis is that that is an unlikely scenario in particular that they would be required to pay back the full amount. In addition, if any amount is owed, that settlement would not occur until 2024. That said, if one CARE were required to repay some or all of that amount, there are a few sources that we believe that one CARE could rely on. Firstly, as one CARE notes in their letter, reserves and assets that combined amount is 5.6 million as we presented last week. In addition, one CARE could choose to kind of hold back some portion of shared savings payments received at settlement from Medicare, the Medicare program or from other programs they receive that in the coming year or in future years to allow them to increase their reserves over time. Furthermore, one CARE has a line of credit, $10 million line of credit as required in their contract, their participation agreement with Medicare, which could be used to support things like this. And if necessary, one CARE could request that the board give relief from this condition so that they could again collect participation fees from hospitals to cover this risk as they have done historically and had proposed to do this year. Questions or board discussion? I had one or actually maybe two Ms. Kinsler. First, you stated that this risk was unlikely to be realized by one CARE. Can you give us a little bit of your understanding of why that's your view or the staff's view? I'm happy to. And if Sarah Lindbergh was on, I would invite her to also comment after I answer to kind of add to her strength in my remarks. So as it currently stands, one CARE spending target for the Medicare program is a combination of the expected spend for the population, for the attributed population and the performance year, plus the amount of the advanced shared savings. So they end up with a spending target that is manually adjusted to be in this year, $9.5 million higher than the actual expected spend of the population. And that is to give us this mechanism of providing this investment in Vermont providers.   That has not happened in past years. We think that the benchmarking of the target setting methodology is very strong and that there's no reason that we should anticipate that expected total cost of CARE would not be accurately set. And so for those reasons, additionally for one CARE to not have shared savings in Medicare or any other payer programs would be surprising. So if there were no shared savings in any program for them to be able to kind of leverage to put toward paying that amount, that would be surprising. If Sarah Lindbergh is on or if Marissa would like to offer any other comments, please feel free. Sure, Sarah Lindbergh, title escapes me in Greenmont Care Board. But yeah, I would say that we preview for Monday will be recommending the maximum allowable trend which we think will offer a very reasonable performance target for the ACO just based on their risk alone. So we certainly, yeah, I think that this add-on, this manual add-on for the blueprint for health should not be influenced by their kind of risk targets in general. And we'll talk more about it on Monday. I know it's always hard to try to separate all these issues. The only other question, I had one other. Sorry, I went out. No, that's okay. The other one was in my perception, this would seem to increase accountability for the accountable CARE organization that is before us. Is there any reason why that perception is incorrect and why that would be a bad thing in this context? I understand the risk. Part of accountability is risk and that is to incentivize performance. Am I missing something on that? I know that's simplistic, but if I am wrong, please correct me. I think the sticky wicket here is these are additional dollars, yes. However, they are distributed to people who aren't even part of one CARES network. So if you're participating in the blueprint for health or SASH for that matter, you're not necessarily in the network. And so they are constrained by our requirements that they may not be duplicative of those programs. And so I think that's just one thing that we should be mindful of, is that they might not have control or influence over some of the providers who those funds are flowing to. That said, those providers' performance isn't included in one CARES performance so they're not measured against those providers' performance. So it's really a way for Medicare to provide an investment in all Vermont providers that participate in these larger, long-standing programs. Thank you. Go ahead, Ms. Lynch. Thanks, sorry about that. Yeah, on this point I think I would, I'm supportive of the staff recommendation, although I'd certainly be happy to understand in more depth one CARES objection to it. I think as the staff has already articulated, these are actually supposed to be passed through funds to support the blueprint and SASH. They are built into, this is the mechanism that was available federally to do so. And there was never I think really an intent that the risk, that there'd be risk for these dollars passed on to hospitals. And that's created a lot of confusion, quite frankly, at the hospital level. And so I like trying to clear up that confusion and making the accountability more targeted to the ACO program. So that's all I was gonna chime in on that point. Just quickly on the Medicare Advantage plan, I appreciated the explanation provided about the efforts to include those plans and why that was premature at this time. But I think it makes sense to continue the requirement, especially since this is a growing area of concern in terms of undermining both the ACO program and the Medicare program generally. So I'm supportive of the recommended approach and wanted to just make those two comments. I too, I'm supportive of the recommended approach. I have concerns with Medicare Advantage and the attrition to the ACO attributable lives that occurs when patients move into the Medicare Advantage program. So I want to continue to monitor that and learn about it. The discussion of risk interests me and I could very well be wrong about some of the things that I'm gonna say next. So I'm completely open to learning more. Whenever we use the word risk, people start to feel like, oh, this must be risky, right? But what I learned last week was that one carers risk, their exposure has declined over years. Beginning, in the beginning, it was about 11% and it's declined to about 2%. Over the last five to six years. While their assets have grown from 3.9 million to 5.6 million. And when I first saw those numbers, the at risk of 11% was what shocked me because a lot of ACOs across the country are 100% risk. That's their business model. That's how they get people to join. They assume all the risk the providers don't. So the 11% was never really high. Thank you, Member Walsh, for offering those comments. I don't think you're off base at all. I think when I think about how one care fits into the national ACO landscape, I want to balance, I guess, like what we know is out there and learning from what we know is out there. I'm recognizing that Vermont is a little bit different. I think some of the Medicare-only ACOs we've had in Vermont are run by national for-profit organizations and organizations with capital that is probably out of just in a different realm than what our local operations are dealing with. But I appreciate your point and staff agree that it's appropriate to build capacity to have more risk held at the ACO level so that there can be more flexibility in investments and payment models in how risk is delegated across different payer types and across, or excuse me, different provider types and across providers with varied capacity to hold risk. So we're definitely thinking along the same lines there. Thank you for the further context, Sarah. I appreciate it. I would like to just make a quick comment on the Medicare Advantage component. I think it's really important for one care to continue to work to try to enroll or partner with Medicare Advantage programs. As far as I can tell, and I think there's a lot of data to support this, that Medicare Advantage enrollment is just going up and up. We have not seen a plateau yet. Vermont is lagging behind that. Game across an article today that discussed that people who are black and Hispanic enroll in Medicare Advantage programs at higher rates than those who are white indicating that this is now a health equity issue. So I do think that that adds another layer of importance that this is a pressing issue that we should encourage one care to work with. I would hope that especially the UVM MVP program would want to work with one care given their shared parent organization and the goals. So I strongly encourage them to continue that work. And I just want to reinforce that. I don't think we need to change any requirements based upon that, but I think this is a pretty pressing issue. Oh, and I don't have anything more to add. I agree with what's been said on all fronts and support these recommended approaches. Great, I do as well. So we can move on to the next slide if Marissa and Sarah all set. Yes, sounds good. Thank you, Sarah and Sarah and board members for your comments. This was really helpful discussion. I'm gonna move on now to the payment models and fixed perspective payment, comprehensive payment reform recommended approach. So again, the black is what was presented last week and there's some modification in red. So the recommended approach here is per the FY22 budget order and FY23 guidance. The Greenmont Care Board staff recommend adopting goals for fixed perspective payment. In the 24 guidance, we are setting those goals at 55% for Medicaid, 24% for commercial, and we are not setting a Medicare goal because we know that Medicare is not going to be able to change the payment model under the current agreement. As well, the ACL must continue to report fixed perspective payment data and progress towards the goals that are specified in the ACL reporting manual. And we want to note that the goals reflect an aspiration, not a concrete plan. The ACL can't do this on their own. It's a negotiation with their payer partners. The ACL shall use best efforts to meet or exceed the goals that are modified by the GMCB and we are adding some clarifying language about the reporting that they must identify and report specific obstacles to achieving the goals and action steps required by one care and partners to overcome those obstacles. And this is supported by recommendations in the all-payer model implementation improvement plan that was published in November, 2020. Are there any questions, comments, or discussion on these recommendations? Oh wait, I'm sorry, there's two slides on this area. The second one is on CPR, apologies. Nothing's changed here. The red here is clarifying. When we say, when the word report is red, it's because last week it said recommendation. We want to clarify that. It was a recommendation last week and what you would be voting on is a required report. That's all that means. These remain the same that they would report on their CPR program evaluation. Continue standard reporting on the CPR program and we are interested in additional information on the impact of moving CPR to a percent of total cost of care. We think this could be done to discuss timing with one care, but we think this could potentially be done in the revised budget. So these two slides represent our recommendations on these payment models. So now are there any questions or comments or discussion on these areas? Yeah, I'll hop on here. So one of the things I'd like to say, I really appreciate the additional clarity we have on gaining some insights into some of the obstacles to achieving the fixed perspective payment goals. I think until we understand what those obstacles are, better and more deeply, we can't solve the problem. So I think that's a good addition. Secondly, I think along the same lines with respect to the CPR program, I would like to add some more specificity to the expectations we have for evaluation of that CPR program. I think we can add it to the budget order with a tighter framework in the reporting manual. Specifically, I think what I'm looking for is a real quantitative and qualitative analysis of the effectiveness of the CPR program in curbing costs and improving health outcomes. Specifically looking for a quantitative analysis or assessment of total cost of care and quality as well as a qualitative assessment of changes in resource allocation and healthcare delivery. How does this fixed perspective payment model impact how providers are delivering care? Are we seeing results in terms of, whether it's reduced ED admissions, increased screening, more patient satisfaction because they have more time with their provider? Are we seeing this enhanced funding going to support changes in the delivery system like investments in onsite behavioral health specialists? We've heard about that. How do we start to quantify it or how do we start to gather more information? We're trying to move to a larger scale, fixed perspective payment model. We have a test case here. So in my mind, I think we need more clarity on how this test case, this pilot, so to speak, at the primary care level is moving the needle on the things that we hope that it will do at a larger scale. So I would just say that I think if we can add it to the budget order that we're gonna have a tighter framework in the reporting manual, some expectations around what does a CPR program evaluation look like? What do we wanna see on our end for a true evaluation of the success of this program along cost and quality dimensions and even changes in the delivery system, the processes? Yes, thank you for those comments. I can address that. What it sounds like you're looking for are specific measures, not just saying, give us an evaluation, but we wanna see these measures. So how we've addressed this is in a couple of slides forward, we'd like to add sort of a specific framework for evaluations, like elements that these evaluations should include because there are several evaluations that OneCare mentioned in their submission that we want to collect. Now, again, it's their internal evaluations, we'd like to review them, but we want to request that the evaluations are here to sort of standard methods for evaluations that they're clear about the measures and metrics used, maybe even in some cases we wanna say, please use these metrics. So I'm gonna review those in a few slides and they would apply to this particular evaluation. Great, thank you, Marissa. So I'll chime in that I wholeheartedly agree with this Holmes' suggestion. I think that what we saw in some of the public comment and from the information OneCare gave us, this is one program that they do that receives pretty high marks and how it's impacting care and cost and what the allocation is to the program I think is really important because this one looks and sounds as though it's one that could have positive impact and if it is, we should see where and we should ensure that it's being funded adequately so that it can achieve those goals. So I agree with Ms. Holmes. I would just like to add, I really support the idea of having an aspirational scale target. I think that if we as Vermonters and Vermon are looking to work with OneCare as a major vehicle of an all-payer model, we need to keep that aspiration high. So I really strongly support that. I'll clarify there, I assume you mean the aspirational FPP target when you talk about scale. Sorry, that was the aspirational FPP target. Yeah, okay. Yes, sorry, thank you. I share that view as well and I'd bend to comment on that and I also appreciate the additional language you have about understanding and disclosing the obstacles and challenges that are faced. If you don't have aspirations and you're not required to report the challenges and concern, there's less effort and without increasing Medicaid and commercial and having Medicare not at the table on this, we have challenges of sufficient scope to have a critical mass to make the changes we're looking for. So I'm glad that you guys included this and thank you for doing so. I'm supportive of the recommendations and I don't really have anything else to add to what others said. Dan. Okay, sounds like we can move on to the next section. And again, doing this section by section doesn't mean you can't go back if you think of something later, but I think this is helpful for framing. The next section is the population health, all the model of care. So I put this slide back up because we updated it from last week to make it a little bit more clear based on some comments. So I'll just review it again. This is the key takeaways from this section. The total population health management expenditures are budgeted for FY23 or 29.9 million. All of these payments go to providers. This is not the cost of administering any of these programs. It's direct payments to providers. That budget is concentrated in three areas. So the largest amount are the blueprint investment, which we have talked about, the per member, per month base, and bonus payments at $17.6 million and the CPR program, which to clarify the entire CPR program is not $1.5 million. The $1.5 million is the investment from hospitals in that program to allow for a bonus payment. So that's money that's converted or diverted from hospitals to help invest in this program and invest in the primary care providers participating. The total amount is funded through payer contracts to pay the fixed perspective payments for their aligned patients. That PMPM, per member, per month population health payment model, has evolved over time to where it is currently. We reviewed that last week. Care coordination has also evolved, particularly in the way that it is reported with the phase out of care navigator. Much of the other funding that falls in the 29 million, so whatever's left after those, the kind of largest bucket, are smaller programs that have been supported by One Care Over Time, some of which their support is phased out as those programs transition elsewhere for long-term funding. And then as well, we know that there's ongoing self-evaluation of which we are requesting to see the results of those evaluations so we can better understand how these programs work and how they use self-evaluation to make investment and budgeting decisions. So that brings me to the recommended approach slide of which I'll double check how many there are before. Okay, so there's two. So the recommended approach here, the first one is pretty standard that once the budget is approved that we require One Care to fund the population health management and payment reform programs as detailed in the FY23 budget and to notify us of any changes, including funding shortfalls, changes in program scope, an analysis for each program line item as to whether and why the funding is appropriately scaled by attribution or some other factor. So this, and they do come back in the spring with their revised budget and say this is what we submitted to you and you reviewed and approved in October and this is how it's actually kind of sugared out because there's a few things in there that are maybe not quite set due to air contract negotiation. So they will report back to you in the spring. There is some benchmark guidance or target guidance set in the 23 guidance around the VBIF or other pre-funded clinical quality incentives, which is just sort of a broader term for what the VBIF is that this is read because there was a typo last week, it said 2.4. It's 2.24 million in the guidance and our understanding is that this is met through funding of the bonus potential in the PHM payment. And again, there's some of that funding is I believe a little up in the air through the Medicaid negotiation so they will be reported in their revised budget. We are asking them to report self-evaluation results to the Green Mountain Care Board. This will be in the reporting manual. The next slide I'm gonna go over that high-level evaluation requirements which we've added for clarity. And the fourth one there is the same recommendation that Sarah Lindberg went over. The blueprint for health and FASH funding requirement usually sits in the population health section but it's I think gonna probably move to the risk section. So it's the same thing that Sarah already went over. We're just repeating it here as well as the proposed 5.2% increase which Sarah Lindberg is going to review that trend on Monday, I believe it is now. So no change here from last week. This looks quite dark in red but it's just because it's new. We wanna add some clarity in the order or in the reporting manual that any program evaluation reported to the board must include standard study element. Some are all or not always appropriate to each study. So there are examples here but standard element. So and there may be some areas where we would request certain elements included for example, the measures that Dr. Holmes alluded to with the CPR program. So we wanna make sure it's clear how these evaluations are being performed. So we would add requirements around that. And that is what we have. Oh, I'm sorry, the heading is, don't worry about the heading. I'm gonna pause there on the population health recommendations and see if there's any questions, discussions, or comments on these. Marissa, actually, can you go to the next slide? The wrong heading. Yeah. Thanks. I like this. And I just wanted to say, I think we should also, where it says participants in study size, sample size I think is important but also selection methodology, who was in, who was out and why, who was excluded from the sample. We need to understand that. I think variables, why they were chosen. And I think backing it up with justification from the literature to say this is a variable that's used often to proxy X, Y, and Z. I think that's important. And I guess I would say in general, if wherever possible, and I know it's not always possible, but it'd be helpful to see comparisons to other studies that are similar measuring performance or outcomes. We need more context and better benchmarking. I think that's what we've been asking for for years. And I would just conclude with, some may say that this prescription here may seem onerous, but I think thorough program evaluation is what every performing, high performing organization should do without need for a regulator to require it. So this is, I think, a good step in the right direction. And we can talk maybe offline if you want about how to set up a little bit of this framework to ensure that we're getting what we need. But I'm happy to help on that. But thank you. Yeah, and these elements are examples, not necessarily meant to be exhaustive, so. Ms. Melamed, would the care board staff be involved in discussing the development of these studies? Yeah, so that is a good question. So these are evaluations that one care reported to us in their budget submission that they are planning to do. I'm a little hesitant to say that board staff needs to be involved in each step of these evaluations. They're meant to be internal evaluations that they then report to us so that we can see them. What we're trying to avoid is sort of an evaluation that is developed for regulators specifically. We want to see the full standard evaluation. But I'm hesitant to commit our staff to sort of insert ourselves into their evaluation process each step of the way. I think I would expect them to perform a standard, an evaluation against standard methodology and then turn it into us. But if you have, you know, if there are concerns about that, we can kind of discuss how this could be done, but that is our intention. I guess I would say I share the concern about being one, staff time and resources and ability to engage in this. But at the same time, I'm sort of balancing that off of some of the, I don't know if resistance is the right word, but, you know, there hasn't been a pursuit of some of the benchmarking that's been asked for in years past and the benchmarking we received this year wasn't in compliance with what the care board had asked for. And I don't want to get in this situation again down the road where we have something that's not reliable or we have concerns about it, we don't understand for one reason or another. So I guess I'm balancing those two things. And I think if it's, you know, sounded like you were saying you have some concern that like it should be for them and therefore they'll be more, you know, objective in their evaluation if it's not for us, but if they know it's going to us as regulators, it's probably in the same place ultimately. Yeah, I understand your concern. I'm going to address the benchmarking report next. I think the difference is that the benchmarking report was a board ordered report. We said it's something they didn't do that we told them to do. These evaluations are evaluations that they told us they're doing and we would like to see them to help evaluate performance. So that's how we've set it up, but I share your concern that if we don't put some specific requirements around what they turn in that we might not get what we want. So sort of compromise or recommendation is to say like please show us how you have, you know, how you have adhered to a standard framework for how to perform a program evaluation and have that be a sort of a stand in for the GMCB staff going every step of the way and telling them how to do it. I'd like to make a comment here. High performing ACOs do program evaluations all the time. And the intent is let's say they have some data that shows that there are a higher than expected rate of avoidable ED admissions and they would like to direct their monies toward reducing that. There's a methodology to how you formulate that plan and lay out what you're going to be doing and then assessing whether it's worked or not so that you could spread it more broadly throughout your network if you had one. So clinical research like this or program evaluation, things like this, it's not a new rocket science. It's out there. The difficulty that I share with Chair Owen and with you, Marissa, that we've asked the board as I've learned that the board has asked for things previously and the response from OneCare, they've either been unable or unwilling to provide it. And five or six years in, it gets hard to tease out what's the difference between unable and unwilling but neither is satisfactory. And so our approach thus far seems to have been to try to be more prescriptive about this is exactly what we want. Another approach that we could consider, the board could learn what it takes to do a proper program evaluation ourselves by reviewing the literature and then comparing what gets submitted to us to what we've learned are the proper ways of doing it. The question that that raises to me then is what is our enforcement mechanism? What do we do if what gets submitted to us remains lacking? This seems this is a budget review. So our levers are to affect their budget, right? But it's not clear to me what that enforcement would be if they submit a program evaluation that is not up to the standards of what we learn to be an acceptable program evaluation. What would we then do? So we have brought authority to collect information. Sorry, I'm probably gonna defer to turn this question over but we have brought authority to collect information if it doesn't meet the requirements there are then enforcement steps which I would let Roth or Chair Foster address if that's what you were going to do. So I was gonna say, unable, unwilling or just a disconnect between expectations, it can be any of those types of things, right? Like it's hard to know or distinguish. I'm just throwing this out as an idea since we're trying to figure out an appropriate solution to this would be perhaps at some interim, they could send us the information on how they're proposing to do it with supporting literature saying this is how it is typically done. And if we need to review it, we can give it a review and let it go on its way. And second, I would say, if one care wants to reach out to us to learn more about our expectation, they should be able to do that. And if they want help and assistance or further guidance from us, I know we're all exceedingly busy but I think that's important for us to do especially since this is so critical to the board. So I would just put it out that maybe they can give us some sort of update along the way so that there's not an issue. And then second, the staff and or even a board member make sure they're available to help with any confusion or lack of understanding between them and us. The other thing I'd say to member Walsh's question is about enforcement. I view this kind of work is very relevant to fiscal responsibility. Understanding where you're using for monitor's resources and how they're being deployed is part of fiscal responsibility. And so I think part of it is if you review a budget without this kind of analysis that high performing ACOs do and that the board has suggested, it is a factor to consider in our evaluation of fiscal responsibility. And what that means for the budget is something that the board members would have to decide. But I think we should give them a chance to do this and do it right. And we should help them if they are unclear on our expectations. That makes sense. I think these are really helpful comments. And I think we can use them to make the conditions or modifications that you would be voting on next week clear to reflect this conversation. Are there other questions or comments on this area? Kind of a segue into the performance measurement improvement, which is the next. These sort of bled into each other. But I'll pause here before moving on. Okay, looks like we're good to move on. Okay, again, this is a slide as presented last week. And this is high level. This is from our high level section about how we were approaching the 2023 budget. That the 22 budget order conditions reflected a focus on data driven monitoring and oversight. So focusing on ensuring that the ACOs management drives continuous improvement consistent with a high performing ACO and that it supports achieving the state's healthcare reform goals. Again, this was envisioned as a multi-year approach. So we're in the second year of trying to implement this. Refining it through this year's process, that's why this conversation is really helpful. And then using this to better inform our 24 guidance. So with the goal of being able to tell one care in advance of preparing their 24 guides, what we expect to see around how they are using their data insights to set their budget. So the staff recommend continuing to strengthen this approach over the coming year and keeping data driven ACO performance monitoring at the center of our ACO oversight. And so the focus here, as we've already started discussing, is on performance benchmarking, target setting, and evaluation. So again, we tried to sort of sum up areas that the board is less than satisfied in performance measurement. So again, this is a slide from last week. And that is assessment of patient and population outcomes at the ACO level against high performance targets and trends. So that's what the benchmarking report is meant to help us see. Accalculating return on investment on one care investments, so including population health programs, administrative expenses. And there's been kind of a standing condition to evaluate that over the duration of the agreement. And then as well, a better understanding of the relationship between one care programs and investments and improved outcomes. So we're trying to get better information around these three areas to help the board understand how one care uses their information to set their budget. So we added one clarifying proposal here. And I think that the red sort of sums up a little bit better what we presented last week. So we are proposing to require improvements to the benchmarking report in the areas of comparison group, measure-specific benchmarking, so understanding how to identify high performers in each area or each category of measure so that one care can use that information to identify best practices. So that's the third one. Identification of high performers to support targeted quality improvement. I think that this should be worked out through the reporting manual, not the staff level, as I sort of started to describe earlier, that the staff has been highly involved in the development of the benchmarking report that we received in October, of which is helpful and a really good start, but it didn't quite meet all of our requirements. So we'd like to continue participating in development of that report at the staff level, as opposed to just telling one care to do it and then accepting a report that comes in. So I do think that this is a place that is important to delegate staff resources to sort of follow the methodology there and refine it. I'd like to, a recommended approach, okay, I'm gonna stick with this slide, is I think laid out here that the areas that we're continuing to try to refine are the comparison group, the measure-specific benchmark and the identification of high performers. How we actually do that I think is probably too much detail for the budget order and we need to do that in our work with one care directly at the staff level. So I don't think that changes the recommendations in any way, it just removes the really specific details that I don't want to make decisions on under pressure, but preserves the specific areas that we feel like continue to need to be refined. So let me stop on this one and see if there's questions because it is complicated and takes expertise beyond mine. And so I just want to see what your questions are to see if we can answer them, if you have them or if you're comfortable with this recommendation as I have described. I have one question. Would it be appropriate or is there a mechanism through which the vendor can report directly to the board in this process as opposed to being a retained vendor by one care? And I guess a corollary to that is what would that do to the funding? Would that mean that the board has to fund this work? I'm not sure we can compel an outside vendor to do anything. We have not had access to the vendor directly and I don't think I can answer that beyond. I'm not sure if we can compel the vendor to engage with us but we could request it. And as to the funding question, I don't know how to answer that. Oh, and can I ask you to clarify a question on that? Please. So are you suggesting potentially the care board funding the benchmarking report directly as opposed to the care board allocating funds to one care to do a benchmarking report? I'm not making a proposal. I just wanted to understand sort of the pros and cons of that but yes, exactly that. Either there's two scenarios. Either one, one care funded and the vendor is working with them and responsible to them and they have a fiduciary relationship to each other in some variety versus the board funding it and having greater access to the vendor or third is questioning whether or not there's a possibility of one care funding it but the board having equal access to or participation in the process with the vendor. The first thing I'll say is if the board were to fund it it would have to go out to bid. Go on that. I would just chime in. Sorry, Marissa, it didn't mean to interrupt you. No, I'm gonna stop on that point, that was point number one. That might be the only point we needed. Yeah, and I think part of the point of having one care contract directly with a vendor to provide benchmarking was so that it could be used with the provider network for delivery system reform and quality improvement. Whereas if we contract with the vendor it won't be used that way. So I think there's a real missed opportunity there if we were to switch forces and do it a different way but to Marissa's point, it would have, I think we would have to fund it. We'd have, it may require additional appropriation. I have no idea and it would definitely have to go out to bid. Significant delays, of course. Yeah. There's also, if we were to assume the benchmarking aspect and then see where, right, there's gonna be good things and not so good things. And then we would be tempted to say, here's some not good things, please start working on this, right? But then we as the board have no mechanism of doing that work.  This isn't working. And what we're talking about is maybe putting board resources into trying to make something that hasn't worked over six years work, but without having the mechanisms inside it to make it work. So I just feel really cautious about that. So if I might offer a kind of a response to the general theme, to echo what Board Member Lund shared, when we introduced this requirement last year, we did consider both of these potential approaches either to do something like this in-house and use it really only as a regulatory tool or to do something, to push one care to pursue a benchmarking tool and a benchmarking report so that it could be used ideally both as a regulatory tool and as a program improvement quality improvement, network development tool so that they could really use that to improve healthcare for ever monitors. While we haven't, this slide I think lays out well the areas in which we would like to see the current report improve. And I think that I would really like to pursue some direct contact between GMCB analysts, analysts from the vendor and analysts from OneCare to understand the analytic decisions that they're making and understand why they have a preferred approach because it doesn't always align with ours as we've noted. I do still think that having the ability to have this report serve both of those purposes to be a tool that OneCare and their network can own and trust and use as well as us using it as a regulatory tool, I still think I still have great hope that that is feasible. And I think we're, you know, we always knew that it would not kind of be a one and done process. So I, so that is why staff are, you know, proposing to continue further along this path, I guess, rather than starting fresh. Yeah, I appreciate the context again, Sarah. It's really helpful to me, you know, coming into this, it's my first season. I just, I want to make one more point that comes to mind while listening in reviewing subject matter experts, submissions to the board over previous years. The one recommendation was benchmarking and it was pointed out in that presentation that most high performing ACOs have a mechanism for benchmarking without a regulator having to tell them to do it. It's part of what they set up because that's how they figure out where they're going to spend their money, time and effort. And the fact that our ACO didn't have that and still doesn't have it, that it's requiring us to tell them they must, that worries me. So that's a good point too. Again, to get some historical context. Another reason why we put in the order for one care to perform this report was because we did ask them about it in the questions and responses for last year saying, is this, you know, we had outside experts say, this is something that they, they see ACOs do. So we said, is this something that you do? And their response, I don't remember it verbatim, but with something like, yes, we consider it and we thought about it and this is something we'd be interested in doing. So we said, great. And we put it in the order. So this wasn't totally imposed on them as an outside condition that they didn't want to do. They had expressed interest. We just sort of maybe nudged it along by putting it in the order. And our understanding is that the one care, they can speak for themselves on this, of course, but that one care leadership and they've expressed to us that the leadership and their board of managers find this to be a helpful tool. So I do think that there's been a good start on it. And then there is a willingness to make it a useful report. I think the tension might be that we are using it for regulatory purposes, which is within our authority to do so and information that we feel like we need to perform proper oversight and that one care is trying to make it the most useful tool for them to support their network. I don't think that those two objectives are that far off but I think that might be why there's been a little disconnect in the way the methodology is done, which I still stand by the way that we have done the report and I think we can continue to work on it this year to make it better and make sure that it's fitting both the needs. And I think we can do so by adjusting some of the methods within these areas that are in red. I appreciate that Marissa and I appreciate everybody and I'm inclined to feel the same way, like if someone were to express to us a desire to work together to do something better, my initial inclination is always, yeah, I will help. But I've had over the past couple of months of reading material, looking at this evidence, growing concerns, right? The one care submitted to us in their presentation, they said they'd made measurable progress, right? And I was very interested in the measurable progress but then they went on to say their measurable progress had been, they listed bullets, modifying clinical coordination, engaging stakeholders, redesigning committees and developing plans. I don't have a strong sense that they see measurable the way that I see measurable or the, and we're trying to give them guidelines to do it. And I, yeah, I'm just, I'm having a hard time having a hard time, seeing that that's, they're gonna be able to do this. So I wonder what we will do if we're unsatisfied with what we get in return. It's a budget process. I liked what Chair Owens said earlier. That made a lot of sense to me. This is a matter of fiscal responsibility. I think we need to think about how do we fulfill our roles as regulators and thinking about fiscal responsibility when we have an entity that's underperforming. So I think to Ms. Kinzer's comments. I think Ms. Kinzer had suggested some sort of, I guess I'd call a hybrid approach. It doesn't seem feasible or productive for the board to take this over. This doesn't seem that way. We wouldn't get it in time. We wouldn't have bids done. It wouldn't happen. So I don't necessarily see the tension between something for a regulatory process versus something to be used in connection with driving quality improvement in the provider network, right? I actually think those things should really be viewed as the same. If there's lessons to be learned for the organization and for the network, that's a good thing. It shouldn't be one report if it's just for the network and a different report if it's for us. And I don't have any real sense, frankly, to really prescribe that to them. I think what that would suggest is that there's some improper thing going on at some level that we'd get something that was not valuable for some intentional reason. And I don't know that I'm there at all, right? Like I think, I'm just in this. This is my first time reviewing this budget and I'm not willing to go that far at this point with this organization. At the same time, I'm highly cognizant of this historical issue and some of the problems that I'm sensing, some trust issues building up over time. And so for that reason, I would suggest that Ms. Kinzler's approach of us having direct contact, not retained, but contact with the organization along the way is a wise one. That makes sense. I would just note that I think there is actually a tension between use for regulation and use for quality improvement, which to me has to do with sort of the culture of how quality improvement typically happens in the healthcare sector, which is quite frankly, confidentially often. So, I think some of that tension is probably felt in one care's board of managers and provider network because they're used to a very different approach to QI. But I'm fine, you know, I'm always fine with staff reaching out and discussing. So, I'm fine with the approach. I agree. I don't think we should take this on because I think we lose a major value in terms of driving improvement in the system. Ms. Lynch, to your point about quality improvement in regulation, I mean, you're right. I think in a malpractice context or any of these other, there's privileged review that can happen so an organization can improve upon the issues. Here, it would seem like we could solve for that and that the data the board would get would be on an aggregated type basis as opposed to Dr. X did this, Dr. Y did that, right? So, I think you could do both here. For sure. Yeah, okay. So, there's already some blinding in the report that they send to us. So, the HSAs and the practices would be blinded whereas internally, one care would have those for their quality improvement effort. Any other discussion on this recommendation? The one thing I would say in all of this is that I think it would be interesting at least to figure out as the board some way to look at the people in Vermont who are not in one care and see if there's a difference between the one care and not one care.  So, I don't know. I don't know how we would do that and that could be complicated, Jesse. No, I was just gonna say, I think that's the thing that... Yeah, no, I talked about that last, I think during the budget hearing or after the budget hearing. And I think we can do that. I think we can do that internally to the degree that we have access to that data through V-Cures and I think our own teams are looking into that. They can't do it as easily because they don't have data on the non-ACO people. So actually only the Green Mountain Care Board can do that. But I think that there's some opportunity for us to evaluate that and we have to look at the resources that we have to do so and the staff time and all of that. But I think it's really important and I hope that we can find the resources to be able to do that. I'd like to... I would just... Go ahead, Tom. Thank you, Robin. I agree. I think that figuring out an analytic approach to this to be able to assess how one program, whether it's this or another, because every program that we try while we're trying to make... While we're trying to improve healthcare, we'll have some good things that happen and some unintended consequences and we'll have to learn from it. So developing our capacity to learn through the state, through the data that we have, I think is crucial. This is not an argument not to do it, but I'll just note that in both NORC evaluations and in the blueprint evaluations, there's a substantial spillover effect, which I think comes from the fact that on the ground, people implement it across the board, regardless of attribution to whatever program. So I think that's just something we need to understand is gonna happen and may understate the impacts of the intervention as well as the fact that we have the blueprint, which will also confound and we can't separate that out. Yeah. I think that's a good point, Robin. And I think from a broad perspective, if the spillover is helpful to everybody, we don't mind. Right? If the spillover seems to be harmful, we wanna stop. So it's a methodological concern if we were trying to be very, very precise and wanted to publish, but I don't think that it's a huge concern from a, certainly from a regulatory standpoint, but just from a public population health standpoint. Sure, but the spillover effect that we've seen to date has been positive, but means that there's very little difference between ACO attributed and non-ACO attributed, which to me, not being an evaluation guru kind of undermines the point of looking at those two populations separately. That's all I was trying to say. It's a great point, thanks for reiterating. If I might jump in, I certainly don't wanna stop any conversation about analyses that we can do internally. I think we have an amazing data team at the board and an amazing set of resources that we can lean on there. I think in terms of the benchmarking report and the analyses that we're asking one care to do, I think the next slide we'll touch on as well. We have one slide that I encouraged Marissa to remove from the slide deck, but now wish I'd left in. Talked about the various approaches that we have to measure and assess performance. We're not looking at just one report to try to, from a regulatory standpoint, assess where one care and their network is at. And so this is just one tool that we have coupled with other analyses that we perform, that our contractors perform, that one care themselves and their contractors perform. And so we're trying to look at all of those things in total. I think, in focusing this slide on the benchmarking report, what we hope to do is to work with one care and hopefully to also have some contact with their vendor to try to get a tool that meets our needs as well. But that doesn't mean that it will be the only thing that we use. And we'll continue to report out to the board about what results we see in all of the data sources that we receive. I'm gonna take that and move on to the next slide, which has not changed since last week. And this is around requiring one care to complete or return on investment analysis comparing their administrative expenses to healthcare savings, including an estimate of cost avoidance and value of improved health. Again, this is a budget order condition that has existed and the measurement is meant to be over the duration of the agreement. So we are now putting a little bit more firm deadlines to complete this evaluation. So we have in here to provide analysis by 630, we would like, okay, it says in here, staff recommend requiring one care to submit a methodological approach with their revised budget submission. And I think that there's probably some board recommendation in here too that the GMCB staff is involved or perhaps dictate that methodological approach. But I think there isn't really anything new here besides this analysis hasn't been done yet and it now needs to be done. Is there any discussion questions about this one? When does this need to be done by? Okay, so the initial, sorry. Go ahead. The initial requirement was to measure it over the original five-year term of the all-payer model agreement. Though the agreement has been granted a short, one probably two-year extension or one-year extension plus one transition year, we think kind of the time is right to do this measurement. So what we've asked for is to have a discussion about the methodology with the revised budget submission, which happens in late March, early April, and then to see an analysis by mid-year, I agree, which we think gives us an opportunity to chime in and provide any opinion that we might have on the methodology and kind of the approach to the analysis as well as to get something in a timely fashion. Can I just make a comment that I, the return on investment on things like care coordination is a really complicated analysis. I think especially in the dynamic patient volumes and access to care at acute care facilities over the last two years with COVID and the post, I guess we're technically getting COVID, but it really feels like a post-COVID period where a lot of people are seeking care. So I really applaud the effort to do this and I think it's really important work. I think that it may be more complicated than we think, and I think we may actually get results that may kind of not feel like they're equivalent to what we're feeling on the ground. So just because of the changing demographics or changing patterns of access that have occurred over the last couple of years. So I think it's really important to do. I just think it's a complicated analysis and I think we should approach it from that lens. It is a really complicated analysis, which is one reason why it hasn't been done. It's not that we haven't discussed and worked on this, especially because you could look at the administrative budget and say, well, you need a return on investment and that however, investments in one care for infrastructure or administration are not necessarily all new costs to the system. Some of those expenses would be done by hospitals or payers. One suggestion is to look at particular programs and figure out the cost of administering those programs and then any savings. I think there are ways to do it, but it is complicated and we need to figure out a way to do it. Knowing that it's complicated, but there are ways that ACOs can measure return on investments that they make in their organization. I guess my one concern is I wouldn't want to disincentivize investments in certain parts of say community health teams, care management, pie of care that when you do the analysis don't necessarily show an ROI, but because of the complexity of the analysis. So I wouldn't want people to avoid potential interventions because the analysis is too complex to show a positive ROI even though there's probably a pretty good ROI. I think that's a very good point, Dave. And I think sometimes the ROI is dependent upon your time horizon as well. And so it is complicated and it will always be imperfect. So one way to step forward into this is to work toward consensus on our limitations. What are we willing to accept as a limitation with the design and methodology that we use? Can we come to an agreement with OneCare or in the future other organizations where we know that it's gonna be imperfect, we know that it's complicated, we're not looking for simple and perfect, that's not, we're not gonna find it, but can we agree upon a methodology where we've discussed the limitations and we're okay moving forward? What I guess our consensus is that we're not okay, not doing this type of analysis at all. That's my understanding unless anyone disagrees, or that's why it's continued to be here. I don't disagree, I just wanna add that I think it would be helpful for the board to provide a framework and a set of methodological expectations or I think we risk getting not what we want. So I wondered if we could with help perhaps from some of our consultants provide that framework, lay out the methodology, provide some analytical guardrails and set expectations for the final product realizing there are limitations, it's complicated, there are gonna have to be assumptions made along the way to do this type of analysis. But I think if we, similarly to the work that you're doing with the benchmarking, staff to staff, I think maybe having staff to staff conversations around expectations around what this looks like. So it's not, the recommendation here is to submit a methodological approach with their revised budget. Well, that's April, May. If that methodological approach doesn't work and we're not gonna get an analysis by June. So I guess my only suggestion would be a slight modification of this is that we provide some framework, methodological expectations for this earlier so that what we get in April or May is more closer to what we want so that the deliverable on June 30th is what we need. I wanna ask a quick question about that which does not have to be answered today. If we're anticipating any use of claims data for this, that claims data won't be available for 2022 by June or maybe it'll just barely be. So I mean, I think it's hard to kind of discuss without at least for me, I don't know which data would go into it and if that has a time in consideration. So, and my only concern is whether or not we have the internal expertise and staff resources to do this, to provide the framework. Maybe we do, I don't know. I think we're gonna, yeah, I think what I'm gonna discuss. Yeah, Robin, I think you make an excellent point regarding potential data sources. My recommendation, a little bit off the cuff would be to work with OneCare to hear their proposed methodological approach in the early spring. And depending on that methodological approach to be able to say, yes, we think it is, we think we would want to wait for additional claims data to come in which would probably be, I'm just looking at like the end of 23, for example. So I think staff are trying to be both responsive to kind of the potential methodological issues and wanting to support developing a robust methodology and also be responsive to the timeliness with which board members and staff and the public are eager for this data and eager to have an indication here. So we're trying to balance both of those things. So my inclination would be to say to revisit it in the early spring when we have a methodological approach with data sources that we can look at so that we're not just talking abstractly. So it's about three o'clock now. I just wanted to give folks a break since we've been going two hours. So while we come back at 3.05 and we'll try and finish up by our hard stop at 4 p.m. So we'll see everyone at 3.05, thank you. Okay, so it looks like we have all board members back. One, two, three, four, me and Ms. Kinsler and Ms. Melmetz. We can continue, thank you. Great, thank you. So we have just one section area of recommendations left and that is on the budget and financial. So I'm bringing back up a couple of slides for context and we've added a little bit of information to them in the red boxes are the numbers, the dollar amounts associated with one care's budget. I think I spoke to those verbally in the presentation last week that I put them in here just in case that is helpful. The next slide is some context around administrative costs and a couple of... No, well, now I'll just, if we have questions, we can talk about these but just in the interest of time these are contextual slides from last week as well as the full accountability summary income statement over time which I think is sometimes helpful for discussing the budget and financials if we need those for reference. So there is one slide of recommendations which are the recommendations we presented last week. The only change here is just a timing issue and it's not something to linger on but the revised budget should be submitted to us by March 31st and then the ACL comes in and presents to us in about a month later, late April or early May. But the recommendations here, I'm gonna go through them and that is to require one character to notify the board of any material changes to their budget and explain variance. So they have one already board order time to do that and that's the revised budget which is submitted March 31st and presented about a month later. But if there are other times during the year where there are significant budget changes for any reason they need to be reported to us. The revised budget should include final payer contracts, attribution by payer, revised budget, final hospital dues and risk. So if you were to pass the Medicare Advantage Shaving risk requirement, for example, they'd have to adjust the risk column to show that the risk has been reallocated. Any other changes to the risk model? Any other changes to population health programs or source of funds for those? And we usually lay out the exact things that they need to turn into us in the revised budget in the reporting manual. We would like to recommend that we require that the operating expenses must not exceed the budget of the amount of $15.2 million. And this includes the cost of all required evaluation and reporting activities as well as any impact on the administrative costs or reserves or such that might come out of the risk arrangement. So there's some impacts on this that don't necessarily change that submitted number. There also are required to notify the board of any use of reserves or line of credit or any adjustment to participation fees. And as well, standard reporting includes audited financials and Form 990 when those are completed. So I'd like to open up these recommendations to any questions or comments. Ms. Melman, if we have additional recommendations for the board to consider, should we make them now or wait? Oh, yes, I'm sorry. Yes, questions, comments, proposals on any of these areas. This now would be the time to bring them up. I had a quick question. The evaluation or reporting that would be included in this budget, do we have an estimation of what that amount of money is? Not exactly. The reason why I state that is because last year the benchmarking requirement was an additional report that we were requiring one care to do that they had not included in their budget. And we allowed them to increase their administrative budget by the cost of that report. So our understanding now is that this, that particular report is already baked into this budget so there'd be no additional needs for that and that any other evaluation or reporting that they are doing or required to do would also be currently included in the budget as submitted to us. And one other question I'll turn it over to other board members. But I have a proposal after the other board members if they have comments or questions to go, but am I correct that the board has never previously not approved one care's budget in full? You mean the financials? Yes. We have made, last year we made an adjustment to the, we made a requirement around funding for the value-based incentive fund which is now set in guidance. And I believe that that is the only specific sort of financial or specific monetary change that we have made like to align item. If I'm forgetting, if anyone else thinks I'm forgetting something, please say so, but that's all that's coming to mind. The only thing I would add is that in 2021 there were pandemic budgets. So those were very different than the budgets before or since. Yeah, that's a great point. On side 24, that reflects the actuals. So there were adjustments, the 20 and the 21 are actuals. There were adjustments based on needs of the pandemic that's kind of outlier situation. But that would be an example. So can we end on the time with the hard stop? I think if we can, we can try and be done with this by three 30s, we have enough time if we can for HCA public comment. My suggestion would be that, as I review the statutory factors with this budget, one that I think the board should pay particularly close attention to is the fiscal responsibility, B1D. And fiscal responsibility is particularly important here to me to consider given the increases in healthcare costs that Vermonters have experienced. And of course the incredible inflationary pressures Vermonters and Vermont businesses are dealing with. One care's website says that healthcare costs are too high. I believe a former board chair said that the costs are unaffordable. And at the hearing on November 9th, one care stated the affordability is a challenge for many Vermonters. And one of our tasks of us, ask of us that we work to ensure healthcare in the state is accessible and affordable and that money is being used appropriately and efficiently. One care was asked if there's a cost benefit analysis done in connection with evaluating how they deploy resources. They indicated there has not been. I think member Walsh asked them to identify a benefit Vermonters have received. And the answer was the amount of money in the number of lives. And it appears that one care has not implemented at least in full board member suggestions or requirements even about program evaluation. And the benchmarking report we received was not in alignment with what we had suggested. And so I think something we're all struggling with, I know I've struggled with a little bit is we feel a little or I feel a little handcuffed and that I don't have a good basis to evaluate some of the programs. Yes, evaluation is hard. However, others do it and it's even harder when you don't make an earnest effort to do so. And so I don't wanna be in a spot next year where we're in the same situation where we are trying to decide if the budget is an appropriate amount of money without really much granularity into the effectiveness of the programs. And I do appreciate the difficulty in some of those, but at least with evaluations, you do get some directional information. And the benchmarking study that we had asked for I think was supposed to be a big part of that. We also recalled upon to review the public comment. I applaud the public for making all their comments. I read them. We talked amongst the staff and myself about various suggestions in those public comments. Some of them are, they're hard to do. People have to do a lot of work. You don't wanna criticize other people. It's uncomfortable. And you have to do it the right way. You won't be right. So I applaud people for putting their name out there and doing that because I think it added a lot of value. And one of the things that caught my eye was the concern about return for Vermonters and also a satisfaction of, I forget the element, but of strengthening primary care and whether or not the allocations are appropriate in the efforts to recruit primary care and retain primary care as adequate. And so given this, I have found that one care has not been fiscally responsible in this past budget. And I would propose that the one care budget be reduced by an amount equivalent to the top five executive bonuses that were received in fiscal year, 2022, which totals approximately $216,219. That is not to suggest that the executive shouldn't receive that money, but I think it's inappropriate for the budget to include that amount of money given the lack of fiscal responsibility. And understanding how you deploying resources and using the money is a big part to me of fiscal responsibility, especially when Vermonters can't access the care they need and they're paying prices that everyone I think says are unaffordable. I'd also suggest that the board reduce the budget by an amount equivalent to the public affairs and marketing budget. I don't have that total handy, but it appears to me that one care has gone through a growth stage as plateaued and is losing share and the marketing needs are smaller than they used to be. And so I would suggest that an ACO that everyone is aware of at this point by and large has less marketing needs and costs that should be included. Lastly, I would suggest that going forward the board received the benchmarking and analysis that we've asked for today with an eye towards what is working and what isn't working understanding and appreciating that there is difficulty in evaluating that and we should be sensitive to that going forward and also not everything that is going to have a positive ROI. There's a lot of great things that happen that don't have an ROI. I think we're all conscious enough of that. So in any event, that is my proposal in connection with this budget. I appreciate that, Chair. I'd like to second your comments about fiscal responsibility. We're six years in and you'd think that we'd have clear answers about here are the outcomes that matter most to Vermonters and here are our priorities as a company. Here's the impact that we've had and here's what we're doing to address systemic issues that are facing our healthcare system and we just don't have that six years in with this. We have an underperforming entity and approving the budget as submitted feels wasteful. Your words were fiscal responsibility. That sounds better. But what I had written down was it feels wasteful. I'm not comfortable approving the budget of $15.2 million. When I can't see what's being done, it appears to be a useful and federally required for our federal contract entity to pass money through from the federal government or from other entities into one care and then out to providers. I don't, I can't see analysis happening in data analytics. I see where in order to receive shared savings someone has to submit data to the payer, Medicare or Medicaid. You can Google how to do that and see that it is not a complicated thing. It's work for sure, but it's not an analytic thing. It's filling in spreadsheets. So I don't see where there's a lot of data analytics the way that we would usually think of that term happening. I'm cautious. I like your proposals, they sound good. But I don't think it's, it could be wrong but I'm not sure that it has to be the board's role to decide where to cut. I do know from prior work that socially responsible healthcare organizations under stress, underperforming or under financial stress they first identify their core functions and then they prioritize the safety, reliability and population needs for the people they serve. And they maintain funding there.  Most socially responsible healthcare organizations will prioritize clinical care, taking care of the people they serve. They forego filling vacancies, they encourage early retirement, they reduce the size of their mid-management and their executives voluntarily take pay cuts for periods of time. It would be telling if one care chose to cut population health efforts, blueprint efforts, sash efforts and maintain their executive salaries, their PR and their communication departments but it's their choice to make. So, Member Walsh, can I just respond? I think I misspoke or forgot to say something which I agree it is not our choice at this time. I don't think it's out of our authority my proposal would not be that those things be cut nor that the board make the decision. They are on the ground, they have a better sense of it as to their manager. So, I agree with you on that and I should have been more clear. I'll have more to say next week. I'm still thinking about the proposal so I don't really have a reaction today. Sorry, Jess. So, I struggle with this a bit. I think that I have had this impression that one care is the major vehicle for cost control health reform, quality improvement in the state of Vermont. That's sort of been my impression prior to these hearings and through the hearings, I think I've come to the understanding that whether by structure or by initiative the cost control efforts are really limited. The quality, while probably largely negotiated data points, really doesn't reflect broad quality in the healthcare system. And so I've really struggled with thinking about value. And I guess I think about value as simple equation in budgets and healthcare is quality divided by cost. And so either you need to get the quality up or the cost down or both simultaneously. And I think we have not clear evidence that quality is up. There is some shared savings that largely covers their costs but as far as the larger costs are rising. So I think there's a lot of discussion in the one care presentation about value added. And I struggled with that term here because it doesn't seem that that is how I use the word value within a budgetary hearing or evaluating a program. So that said though, I think that part of this I think is maybe potentially a structural issue. And I guess this is a conversation that's long ongoing and predates me substantially but that with an ACO that has hospital representation largely in the board of directors is gonna be motivated to support initiatives that are gonna keep hospitals sustained which is super important. We need to have thriving sustainable hospitals that do well but there are differing goals there that a hospital needs to generate revenue and maintain a revenue source and us as regulators in Vermont representing Vermonters trying to improve quality access and affordability we have the affordability duty. And so this is where I've been really struggling with understanding one care's position in all of this. I think that where I've come to is that I don't expect a whole big shift in cost or quality with what one care is capable to do. And it does appear that over time they generate more shared savings than they cost that administration whether or not that's the right balance I'm still struggling with. So I guess that's my general thoughts on the topic. I don't know if I, how I would feel about specific numbers at this time. Dave, I appreciate you sharing your sense of struggle and I just, I wanna take a moment to say that I share that, I was trained and I teach at the place that came up with the conceptual model for this. Like I have believed that it really can work. I've seen places where it's worked. It's not working here. And how much longer do we continue to put more and more resources into it? I'm struggling with, right? Because I would like to see it work. And it's been an eye-opening several months. I did not come into this period of the calendar with feelings, anything like what I've gotten from reviewing the evidence that's been presented to us over the past few months. So it's, I wish things, I, yeah, it's a struggle. But I've struggled to find the value that one cares bringing to Vermonters. I think I'll just, in the interest of time, 3.30 being our point of reference to try and open it up for the HCA and public comment, which I wanna make sure we do before our hard stop at four. I'll say, first of all, that I support the staff's recommendations on this particular component. And I appreciated hearing, Chair Foster, your proposal. I think I wanna think about it in the context of some of the other changes that we're already making. So for example, if we do potentially move towards shifting risk to the ACO, that's something to consider with what their operating expenses are. I also wanna say where it sounds like we're gonna be requiring more and better evaluation. So they may not have enough resources given, I think that they've put in their budget, the hiring of one evaluator. Given the expectations that I think we've laid out today, they may need to enhance that. And I just would say too, I think it's important that we look at their admin expenses. And again, I just have to think about all this, thinking about what their admin expenses have been over time, what the expectations of what they would be doing over time might be in adding an inflationary component to it. So for example, if you look at their admin from last year to this year, it's actually fallen. And if you incorporate an 80 or 9% inflation right on that, it's really fallen. So I think these are all the things that I'm thinking about, that I will have to think more clearly about between now and next week, but I appreciated all of the conversation so far. Is there any other board comment questions or proposals? And hearing none, we'll turn it to the healthcare advocate. Good afternoon all. First, an appreciation for the board. Staff and for the board for a really thoughtful conversation about a number of really tough dynamics, tough questions and tough dynamics. In particular, your recognition of the importance of rigorous evaluation, we support. I want to encourage you, I know it's been discussed, I want to encourage you to think about interim reports from one care to the board as a way to measure progress on that rigorous evaluation. I also want to mention sort of a difficult structural dynamic in the event that your evaluation of one regulated entity involves directly another regulated entity. Just, I just want to make the plug that we need to create forms where it's only fair to have everybody at the table if we're able to have those conversations. And of course the HCA continues to stand behind its comments. And I also want to recognize the conversation that happened right at the end I appreciate the direct recognition of what Vermonters are facing, the financial barriers that Vermonters are facing as they need to get here, as they attempt to get care and attempting to apply that pressure, that recognition in your deliberations. So thank you. Anyone else from the healthcare advocates office? Great, and we'll turn it over to public comment in the order in which the hands were raised, although I think they just flipped. I think I saw Ms. Aronoff's hand raised first. So she's number two on my thing, but I think she was first actually. So please go ahead, Ms. Aronoff. Hi, good afternoon. Thank you, thank you for making time for some public comment. Earlier in the afternoon, I sent Sarah Kinsler a legislative report. I understand she has shared it with board members. What that report is, is it's how we have spent our Medicaid investments? Oh, I'm sorry, let me just back up a second. For the record, my name is Susan Aronoff. I do policy work for the Vermont Developmental Disabilities Council. In the area of healthcare reform, I really focus on Medicaid and how our Medicaid is spent. And our Medicaid is spent on this healthcare reform effort in a lot of ways. Some I don't really understand, but I will never oppose. We, you guys are duty bound to support rate increases for primary care providers. So we pay Connecticut rates, go Vermont. We are not Connecticut. I did healthcare work in Connecticut for 15 years. That's what we pay for primary care. How do we do that? Can we short? That's a mandatory service. We have optional services in Medicaid. We have to pay for nursing homes. We do not have to pay for home and community-based care. Our Medicaid investments in home and community-based care are reflected in that handout. You'll see all these nonprofits, all the people who provide mental health counseling, substance use, look at that list, Northern Lights, the Lund Home, every single one of them. You'll also see some administrative expense. Green Mountain Care Board is there. Healthcare Advocate. If you turn to divas expenses, you'll see it's color-coded and there's a block that represents what divas spent its Medicaid on. And you'll see a special term in condition, 83. You'll see that all of that money, Medicaid, straight-up Medicaid, went to One Care Vermont and only One Care Vermont. That Medicaid money under our last global commitment waiver could have gone to our designated agencies and our specialized service providers. Instead, under the direction of Algo Bay, that money was first put out for public bid. I will send this to you in my comments that I plan to submit on Friday and then pulled back and never again, never again, submitted for any kind of public application. All of that money went directly from diva to One Care with no, it often went through the budget adjustment process. Anyway, what my question for you, Mr. Chair, at last year's hearing on the Medicaid quality results, I posed the question, the way the prior chair worked it was that if the public wanted information from One Care, we had to ask you, Mr. Chair, to ask them. And if you thought it was relevant, you could ask them to provide it. My question then, and I think it's really relevant to your conversation and to helping Vermont understand what value they've gotten for their public dollars, is I would like to know over the course of One Care's existence, how much money it has received from these three very specific pots of public funds. First of all, Medicaid. And I don't mean what they've received in their contracts and their administrative rates for the Medicaid next generation. I mean, I mean that too, because they got favored nation status in the beginning. Oh my God. I mean, specifically, these investment funds and someone someday should look into why there is no public accountability and how it is. Julie Wasserman, look at our comments, follow the money, Agobay, Corey Gustafson, they control the money, where are they now? What are their salaries? It's unbelievable. And when you care about Medicaid and you care about public trust and accountability, if you might find it a little offensive that one or two people got to direct these millions of money, dollars, that could have gone to home care for people who instead are living in hotels because we need a hundred shared living providers for people with developmental disabilities alone because they can't afford their workforce. So one pot of money, what did they get for Medicaid? What has the public spent for one carers health information technology? Each round of it. I was fortunate to work with people, really great people like Sarah Kinsler and others on Vermont's state innovation grant. We spent a lot of money on healthcare innovation in Vermont and a lot of that money went directly to one care to help stand them up, of course. But what have we gotten? And where else could that money have gone? And look at the people who are really lagging behind in health information technology now and what a difference it would have made to people with disabilities during the pandemic if we didn't have to scramble to get everyone a fricking iPad and some kind of activity so that they could receive some kind of service because they weren't getting their regular services. So HIT and then the third pot of money. And this is where you've got to look at the all-pair model agreement executed in October, 2016, hand in glove with our global commitment waiver also executed in October, 2016. It was intended, very well intended. We expected we'd have President Clinton who was very well intended that our Medicaid investments would flow in a certain way. Certain systems would work in certain ways and it just didn't happen. No one expected President Trump, no one expected the gutting of the ACA. So money that was designated in October, 2016 to go to one care went to one care. And those are the funds I would like you to look at directly. One care got 10 million right off the top as startup costs under the all-pair model agreement. There was other just direct monies they received outside of, so it would be like the state innovation grant you'd have to look at for health information technology. Anyway, last year, Mr. Chair, Chair Mullen asked one care, hey, could you add up what you've received from the public over these many years so that we could look at it for the return on investment and this cost issue? Because when I look at Medicaid, just Medicaid, I wanna find a simple relationship between Medicaid's investments. And how is that benefited? Medicaid recipients. And I don't mean just the attributed lives. And I think if you wanna know, I think Alicia Cooper over at Diva might still be running numbers every year on people attributed and people not attributed and how do they compare to answer your other discussion. Anyway, and she's brilliant. So you might check in over there. But the other people who depend on Medicaid every day to get out of bed, the people who need home and community-based services, the people who need a viable community-based system and those funds, specifically those funds and that global commitment report all went right to one care. Part of our platform this year is gonna be some Medicaid equity. Hey, legislature, could you give to the community system the same amount you gave to one care? It's millions. That chart by the way you have is sort of messed up. You'll see the numbers don't add. Alicia Cooper, the brilliant one is gonna be submitting those soon. It's publicly available on the legislative reports page. So that's it and thank you for the time. I'm sorry, you asked me a question. Ms. Aronoff, your question was would I ask one? Is that what you asked me? Yes, so in the past, this could either be in your budget order or in a request to one care for further information, a tally of how much they received in these public funds. It's very, I would do the math myself. I've tried, believe me. It's very hard to find the numbers. And then when you think you found them like this legislative report, you look at it and you realize it's wrong. So anyway, there you have it. So I'll take up your question. I have to speak with the staff and the attorneys and everything, but thank you and I'll note that for myself. And I just wanted to say just thank you, Mr. Chair and thank you so much all the members for the manner in which you've conducted this year's hearing. As a member of the public who's commented in the past, people are feeling heard and read this year in ways they haven't. And so I'm encouraged to submit my comments this year. In the past, it felt like a preform, a thing to do for the record. So anyway, thank you. Thank you all for your service. Great, thank you. Thank you very much. Next, I believe the next hand that was raised was Ms. Oxfeld, Ellen Oxfeld. Yeah, can you hear me? We can, yes, how are you? Okay, hi, yes, my name is Ellen Oxfeld and I'm a faculty member at Middlebury College. Healthcare is not my area of academic expertise at all, but I've been involved in healthcare advocacy for many years in Vermont. I would like to urge the Green Mountain Healthcare Board to keep your vision of healthcare in Vermont attuned to the notion of healthcare as a public good as laid out in Act 48. We really do not need another experiment like the ACO, which as you are coming to see has wasted precious time and resources. Now, what I want to say today is that the whole idea behind the ACO and other recent reform efforts has been the belief that what really ails our healthcare system is fee-for-service. This supposedly drives excess costs and leads to over-treatment. That has been the assumption since the early 1970s when President Nixon started the HMO movement. But the fact of the matter is that excess U.S. healthcare spending is not driven by fee-for-service. It is basically driven by unnecessary administrative costs due to a fragmented financing system. That's the biggest driver, about 34% of our excess costs, excess healthcare dollars are driven by administrative expense. I would like to add that under-treatment, not over-treatment is often a cost driver, expensive complications occur due to lack of access as people defer or avoid treatment due to high out-of-pocket costs. We know that in Vermont, 44% of Vermonters privately insured under age 65 are now under insured. And absolutely, if you compare to other countries with universal systems, we aren't even over-treated in this country. We don't spend more time in the hospital. We don't get more tests, but they all have much lower per capita spending due to unified healthcare systems and the ability to plan for the entire population. I know you are all, and I saw it today beginning to ask questions about the ACO. I would just like to say, it's not just the management of this particular ACO. It's really the concept. Think about it. A whole new administrative entity was created to fiddle around with ending fee-for-service, which wasn't the problem in the first place. Look at other countries around the world. They all have different payment schemes, usually a mix, some fee-for-service, some capitated payments, some salary, whatever. They've got a bunch of different payment schemes. None of them are perfect. All of them can be gamed, but none of them are said to be the definitive cause of excess costs. In fact, they all have lower costs than we do. We can bend the cost curve by creating public financing and universal access, simplifying administration, cutting out unnecessary middlemen like the insurance companies, and I dare say the ACO. We can't do it all at once. I understand that. But we could start by making primary care a universal public good. We all say primary care is the absolute foundation of any effective healthcare system. Universal primary care would create great administrative simplification. We could create a uniform and fair payment scheme by pooling funds for primary care that would address payment disparities. It would help primary care providers. And if I dare say, would actually probably attract more primary care providers to Vermont. I just have two more quick comments because I know we're running out of time. One is about the idea of global payments. Now that's been raised as of interest lately. That's a great idea in a single payer system. I am having a very hard time figuring out how this is going to work with our current fragmented financing system. How do you create global payments for our 14 Vermont hospitals when you have so many different payers? What will each insurer pay each hospital? And let's not forget insurers are not gonna want to pay for charges that are part of a patient's deductible. So we will still have to have some kind of fee for service in some form or fashion and that complex paperwork will remain. Finally, another current buzzword is value-based care. Now, let's think about this for a minute. Value-based care is defined in the latest or the last couple of issues of health affairs as simply anything which is not fee for service. So that's a very general and not specific catchall phrase. And it goes down that same assumption, I will call it a faith-based assumption, that fee for service and ending it is what we really need to do in order to save costs in our system. That has not proved to be the case for four decades. I don't think we can try it for another four decades. I'm not sure. I'm not saying fee for service is great, but it's not the cause of our ailments. Now, I know you're not lawmakers. If you want to get back to implementing Act 48, they will have to step up to the plate, of course. But I want you to know that they look to you for direction and they really follow what you say. And I know the last seven years or so, we were told time and again by lawmakers, oh, we can't think about universal access now because let's see how this ACO works. We've got to see this through to the end. So they do look to you. In the meantime, one thing I would like to urge you to do is maybe get back to the health resource allocation plan. I could be wrong about this, but I think it has not been updated since 2009. I think according to state statute, it should be. It would help address issues of redundancy in our system, which could be a cause of added costs. And it would help to create a more efficient use of our healthcare resources. And that's something that would support rather than deflect from the goal of ultimately implementing Act 48, which has not ever been taken off the books. And it's our roadmap to making healthcare a publicly financed public good. And Mr. Foster, I just want to say, I do hope that you take, I know you guys have been meeting with different kinds of advocates around the state. And I do hope you take some time to meet with universal healthcare advocates at some point. There are many of us here in Vermont. We have a different point of view. I think many of us have, if I dare say, I think we know something as well. And it would be nice for us to be able to meet with you and the board, especially some of the new board members and just provide that input. So that's the end of my remarks. And thank you. Great, thank you very much for your comments. Next, I believe we have Victoria Loner. Yep. Thank you, Vicki Loner, CEO, one care Vermont. First, I just wanted to address that I think that there is a fundamental disconnect. Maybe it's a disagreement on what an ACO is supposed to be in charge of in the all pair model versus what the state, the policymakers and the Green Mountain Care Board is supposed to do within the model. An ACO as part of this model and it was created back in 2017, implemented in 2018. So we're in year five. The terms of what the ACO was to do was pretty clear. We were to enter into value-based contracts with payers in Vermont. We were to engage the preponderance of healthcare providers in those contracts, which I will note we have done to date. We were to set financial targets with payers and we were to look to meet or exceed those targets. And if we exceeded them, then we were to have providers be accountable financially to pay those back. We have done that with Medicaid, Medicare. We have continuously come under the benchmarks that were met for us or set for us and Medicare and Medicaid over the last five years, even during and before the pandemic. The most recent NORC report shows that we continue to provide high care, low cost services. If you look at our quality in the first two years, we maintain very high quality compared to other ACOs across the country. That is a measurement of success. The NORC report will show that even during the pandemic, Vermont's quality and inching towards those benchmarks are on target at the ACO level and the state level. So it's very hard for me to sit here and have this conversation about the value judgment of what one care has or has not done. So maybe the conversation needs to be is what is the board's expectation of one care of Vermont and its providers? Because those expectations were pretty clearly set at the beginning of this model and we have worked in good faith as a partner with the state to help you implement your all payer model. I will say that we are the only ACO who has agreed to actively participate in this model with the state. That wasn't by design, there was opportunities for other ACOs to participate. I'm sure I'll have more written feedback for you but that's the first comment I'd like to make. The second was more mundane around the overall risk and taking on the blueprint risk. Like to just address a few issues that were incorrect in the staff's presentation of the risk. One care was never designed to be a risk, a fully risk bearing entity like an insurance company. We were designed to be able to be a pass-through entity to share risk among our provider participants who would be accountable for the care that they delivered. Remember one care does not deliver care for the care that they deliver to the participants and we would support them as a shared infrastructure and doing that. That's why our risk reserves have never been high because that was not an intention of one care by design. If the board wants to talk about us changing our design and taking on more financial risk, I think that's a different discussion. Currently, the amount of risk, it's not a 0% that we couldn't blow through that we, the provider network, couldn't blow through the target, we could. The money that is in the blueprint right now is more than we have in our assets. So if you wanna talk about financial responsibility, it's not financially responsible for us to gamble when we don't have enough money to pay it back. You could tell us to take it from shared savings, but remember the way that our contracts are designed with providers is they receive 100% of shared savings. No shared savings are returned by the ACO. So that is not a mechanism in place right now for us to be able to take those funds to repay. We could use our line of credit to be able to do that, but again, we have to pay that line of credit back and we do not have enough money on our balance sheet as it currently stands to be able to pay that money back. So it would be fiscally irresponsible for us to take on more debt than we could pay back at this point in time. Thank you. Thank you very much for raising your hand and for your comments, I appreciate that. Next, we have Walter, how are you? Please go ahead. Hi, Owen, how are you doing? As a 10 year groupie of the Green Mountain Care Board, this has been one of the more interesting discussions. I just wanna say I agree with Tom, David and Owen's assessment of one care. I won't get into it. I just also wanna ask that as a patient, someone who almost died at the hands of our healthcare system before one care and now as a patient going with one care on the landscape, the access, the quest, everything hasn't changed one bit. So how has it changed? Why I agree with the fiscal responsibility, also accountability as well. And I agree with Tom when he's been saying that essentially he hasn't been able to find any evidence of one care is what one care is brought. So I'll leave it at that to let others go. Thank you very much for your comment. Next up, Ham Davis, please go ahead. Thank you. I realized that there's just a couple of minutes left. I would just say two things. One is that I still am just amazed by all of this that when you're looking for the, you had a slide up there that said you were looking for high performers. You don't have to look very far. They're right in your, in the Green Mountain database. Green Mountain, they've got, you've got PQI rates.  You've got cost rates per capita. You've got all that data and you're just ignoring it. Secondly, so I said that before and I'm just reiterating it. Secondly, I would just say the idea that you don't need that you don't need to get rid of P for service I think is ridiculous. I think, and there's nothing, that's the most silly thing I ever heard. Third, what I would say, what I would say is one of the things that you, that I don't think you've looked at, you've looked at virtually everything today, but here's the thing that it's, I think what you're really looking at here is you either, you're the only way you're gonna really change this to make yourselves all happy with it all is to kill one care. And that can happen. If there will be considered, I believe, people, the one care itself will have to be decided. Well, it will be UVMMC that basically will decide it. UVMMC will have to decide whether just fold one care, just forget about it, move all of its people inside so they can just focus on the UVM network, okay? Your costs and your quality outside the UVM network are absolutely terrible and you guys are just hiding it. So that's what you're looking at. You're really close. Give it up, tell, if you don't want one care Vermont, just tell them you don't want to do it. They'll shut it down. Thank you. Great, thank you very much for those insights. And I don't see any other hands raised. Are there any other hands raised? I believe the folks who have to travel are going to pick it up by phone or watch the video if they miss anything, but we didn't want to cut off public comments. So are there any others? Great, well, thank everyone for focusing on this issue and for everyone speaking up today. It's very helpful to all of us. With that, is there any old business to come before the board? Any new business? And is there a motion to adjourn? To move. Second. Will those in favor? Aye. Aye. All right, thank you everybody and safe travels to those getting on the road. Thanks.