 Okay, I see that all the board members are back. So I'm gonna reconvene the meeting that we recessed this morning until one o'clock and we'll get started. And this afternoon's topic is gonna be about one care Vermont revised budget presentation. And at this point in the meeting, I'm gonna turn it over to Marissa Melamed to lead us through this discussion. Marissa. Thank you, Mr. Chair. Good afternoon, board members and the public. I'm just gonna kick this off with a very brief introduction to grounds everyone in the ACO revised budget process. I'm just gonna share a couple of slides. It's showing up all right? Yes. We need to make it bigger. Okay, great. So the budget guidance and the budget order require that a revised ACO budget is presented in the spring of the budget year. And the revised budget and the presentation must include elements that are described in the FY22 budget order, which are on a later slide. The budget adjustment process is established in rule five, section 5.407. So staff is in the process of reviewing the revised budget, including this presentation from one care today. We'll come back to the board with any performance that has varied substantially from its budget. So we're scheduled to present that next week. If performance has varied substantially from the ACO's budget, then upon application of the ACO, the board may adjust the ACO's budget. There's a potential vote noticed for May 11th because One Care has requested a modification to some of the language in its budget order, which they will discuss today. The presentation needs to include the following elements that are in the budget order. So this includes final 2022 attribution and finalized payer contracts. The revised budget numbers based on that final attribution, final description of population health initiatives, expected hospital dues, by hospital expected risk, by risk bearing entity and by payer, any changes to the overall risk model for 22, the sources of funds for One Care's 22 population health management program, the status of the ACO benchmarking system by payer program, update on the results of evaluations as described in the FY22 budget submission. Specifically, you asked for an update on care coordination and variations in care analysis that were discussed during the budget process, as well as an update on the partnership between One Care and the University of Vermont to explore additional partnerships around evaluation. One Care's progress relative to its targets for commercial payer fixed perspective payment levels that have been discussed throughout the budget process, as well as any other additional information that the Board deems relevant. And finally, this is the specific language in section 5.407 for your reference in this process. That is all that I have today. If there are any questions that I can answer about the process, I'm happy to do so or else I'll have Russ McCracken available for any legal questions that you might have. Board members, do you have any questions of Marisa or Russ? If not, Marisa, do you want to introduce our guests from One Care? Happy to. Looks like we have today Vicki Loner, CEO of One Care Vermont, Sarah Berry, Chief Operating Officer and Tom Borey's VP of Finance. So I'm happy to turn it over to them. All right, I'll get us started. Hi, everyone. I'm Tom Borey, the Vice President of Finance. Nice to see you all today. Building on what Marisa just presented, just thought it would be nice to orient everyone to the process a little bit before we start sharing slides. We submit our budget to the Green Mountain Care Board on October 1st, typically. And at that point in time, there are many estimates in our budget bill. Attribution is estimated, total cost of care targets are estimated, and our contract negotiations with payers are still in process and have not concluded. So it's kind of a nice process. We come back in the spring and really explain to the board and the public what has changed since the initial budget submission. We'll also address the other topics that Marisa just outlined previously. What we won't do is recast the whole budget tip to tail, but we're really gonna try and focus on key areas of change in that particular area, and then we'll make ourselves available for questions as needed towards the end. All right, I'm gonna share my screen. All right, make sure we're gonna get the right file. Can everybody see this screen? Yes. Thank you, Chair Mullen. All right, introduction here. We've broken the presentation down into two different components. One is updates as requested on the population health management programs, go through those, and then shift into the actual budget itself with a little bit of a look at attribution, revenues, expenses, et cetera, as we dive in. So we get started on the population health management descriptions and status. PHM is population health management for reference. High levels, there's not a lot of change here, but I do wanna note two updates. The first relates to the second bullet regarding complex care coordination program. You may recall that during the budget process last winter and fall, the complex care coordination program was in flux. We were transitioning the payments from Care Navigator being the source into a new platform. So there are some movements remaining as we presented our budget. Just wanted to close the loop here, the committee that we have finalized any performance measures for which the providers are accountable and communicated those performance measures accordingly to those providers. So we're effectively up and running for 2022. The next is the Value Based Incentive Fund. I'll speak to this a couple of times in the presentation today. There was a more significant change in this particular program area that relates to the Medicaid component of the Value Based Incentive Fund, notably that the Medicaid Value Based Incentive Fund will be fully funded by Medicaid and paid by Medicaid directly to providers. One care remains the administrative entity for the quality evaluation, will determine the payment amounts and communicate the recipients accordingly to Medicaid, but Medicaid will ultimately make those payments. As I get into the budget section, I'll speak to that in a little bit more depth. All the others, the Population Health Management Payment, the CPR program, as well as specialists in innovation, no substantive changes to the programs themselves, but there have been updates to reflect attribution or timing in some case, as it relates to the specialists in innovation funds. To speak about evaluations, this is a topic that has been pretty active within OneCare, really trying to measure all of our programs and their effectiveness over time. Starting at the top, the Care Coordination Evaluation, this one is underway. The teams are actively working on this. We anticipate having an evaluation completed this summer. We'll work through our board to make sure they're informed as well. And then we'll likely include some content related to this particular topic in our budget submission, which we'll start writing during the end of the summer. I will say our approach in this evaluation is to really think about this holistically and broadly. Yes, claims data will, of course, be an important component of the evaluation, but we also want to think about patient and staff thoughts through surveys and other means to make sure we're getting a full picture of this program. Next bullet down around data policy reports and applications. Important point to mention here is that we just continue to refine and expand our reporting suite and strategy with our network and make sure that the data that we receive from payers and their claims feeds are put to good use and we're effectively using those data feeds to help improve care delivery patterns across our state, which leads in nicely to the HSA consults, the second to last bullet. This is a process that we really rebooted and revamped in 2022 and our design or desire here is to focus on actionable data for HSAs. Generally the way that these work are that OneCare and the analytics team and finance teams and other leaders come together with some strengths for each HSA as well as some opportunities. And the best part of the meeting is that we engage in a dialogue. We sit down, we share what we're seeing from our end and hear from the HSAs. They know a lot more about what's going on in their community, their areas of focus, and through these discussions, we learn a lot. Hopefully they get some takeaways as well. And then throughout an annual or multi-year process, we try to come back home to those initially discussed strengths and opportunities and monitor improvement over time. So continuing process, really excited about it, great to engage with the HSAs directly in this manner. To speak a little bit about OneCare's Evaluation Contract with UVM, this is an engagement with the UVM College of Medicine Center for Health Services Research Team and they're really supporting our evaluation work and there are three domains. First is ACO key performance indicators. For anyone who spent time in healthcare or playing with healthcare claims data, there are many, many rabbit holes you can go down. So what we're trying to do through this work is define a really solid list of KPIs that we continue to focus on over time. And making sure that our work with UVM comes in is making sure that these key performance indicators are supported by literature, research, and that we have the right process and identify the right core set that we can really keep focus on over the next few years. Next is a network survey. We always want feedback from our provider participants, but surveys are all not created equal. So we're making sure that when we do create a survey, we're doing it in a proper manner which yields quality results. So the UVM team has expertise in this area and they're helping us in that particular space. And then the last one, as I mentioned previously is program evaluation similar and that we're leveraging the expertise of this Health Services Research Team to make sure that when we're doing a program evaluation we're using best practices and generate high quality results that we can use to inform our future. Shifting gears, ACO benchmarking update. So for those who may not have been quite as close to the budget process last fall and winter, OneCare was ordered to purchase a benchmarking tool that can be used to compare the providers participating in the OneCare ACO to providers participating in other ACOs. And through that process, identify areas of strength, areas of opportunity and help us understand the nature of the health system within OneCare Vermont relative to others. As mentioned earlier in the meeting today, we have submitted a request to amend that budget order. And I wanted to speak to why a little bit. Really at the very top, the intent of the budget order met the request is to ensure that we can comply and we've learned quite a bit through the process thus far. First is we've asked that the focus of the benchmark reporting remain on utilization, cost and quality. Those domains are relatively wrote in our healthcare world and there are data available. What has been challenging we've learned is patient satisfaction engagement and evidence-based clinical appropriateness. While those are very reasonable areas of interest, there are not means that we've found that would be able to help compare OneCare providers to other providers working in ACOs. That's been a challenge for us. Next bullet is flexibility to work with the vendor to identify specific measures. This points back towards that KPI work previously making sure that the measures that we are benchmarking are relevant to our focus and the work that we're engaged in over the next couple of years. So some flexibility in that front is requested. And then the last bullet relates to the different payer programs. Medicare data seem to be most available. There are some data sources that can be used to compare to other ACOs, but we have experienced challenges finding established benchmarking solutions in the Medicaid and commercial domains for a couple of reasons. One is they're all different. Every Medicaid entity across states is all different and really not consolidated in any way like Medicare data often are. And there just really hasn't been any kind of vendor or entity that's wrestled this to the ground yet. So it's been a challenge for us to find a solution that would manage the cost of the engagement in these particular payer lines. So we're moving forward with full steam on the Medicare side, but we have encountered challenges with those other payer lines. So with that shifting into our actual process to find a vendor who can meet our needs to the best ability possible and comply with the Green Mountain Care Board and the amendments that we've requested. We've spoken with a number of vendors. A lot of them had interesting products and interesting approaches to benchmarking ACOs against one another. It is hard to do, but there's some interesting strategies at foot. Key considerations for us when we were speaking with these vendors, the vendor experience, have they done this before? Can they help us match fairly and appropriately to other ACOs? How much data do they have? Is it just a small amount that we can compare or do they have vast data sets? Ability to benchmark with other ACOs versus just more general Medicare averages. Cost, of course, customized ability I think is important one. For example, if we find an area of interest where we're not performing at a level that other ACOs are, we'd like to be able to dive in and drill in and understand more about it. So that was an angle. And the needs of integration speaks to how much resource need is consumed by getting this propped up and up and running. The limitations, largely I spoke to those in the previous slide, unavailability of data in a couple of those different areas, the Medicaid and commercial limits I spoke to previously. Cost, we did put in a $150,000 budget increase for this particular expense as allowed by the existing agreement and care board budget order. The frequency of the refresh is something that we're talking about it. This is one where it doesn't make sense to refresh and pay to have it refreshed every single month because not a lot will change month to month, but maybe twice a year is appropriate where we can see if any emerging changes or trends are emerging. As far as the next steps go, we have received agreement and care board approval of our desired vendor and we are in active discussions with them to finalize the agreement arrangement with them and get the work started. So hopefully in the summer we'll have some first looks at data. Okay, so now we're really shifting into the budget section. And again, I'll be highlighting some of the bigger changes that we've experienced between the initial budget submission and what we're seeing now. Starting with attribution, the table included here is effectively the start of the year attribution. This is not an attrition affected table at all just the beginning of the year. For Medicare, it came in very close to the initial estimate off by just 923 lives. Just to say it about Medicare and all these other programs, there is attrition that occurs during the year after this point, so the lives lost to Medicare advantage or people who become ineligible throughout the year will taper that number down as the year continues on, but these were the starting numbers. For Medicaid, we saw strong attribution in both the traditional and expanded cohorts up about 7,000 for the traditional and 2,000 for the expanded. So that's great for the providers that hopefully a higher percentage of their panel is attributed if their Medicaid lives. And we did see a little bit of a decrease in Blue Cross QHP, but no material effects on programs overall. I'd like to note that for MVP QHP and the Blue Cross primary programs, at the time the budget revision was submitted, we did not have attribution updates. We have since received some data. It suggests that all the attribution numbers here are gonna be just a little bit lower than what we anticipated. So I think once the QA process is complete, we'll probably be right around the $290,000 live range for total attribution to one care Vermont. In the payer contract space, the Medicare and commercial contracts ended up being pretty true to form. In other words, the estimates or assumptions that we put into our initial budget submission ended up being very close to what ultimately occurred through the contract negotiations. Medicaid, however, has a number of changes. First, we have PMPM funding. The amounts that one care receives has been reduced from $6.50 PMPM to $4.75 PMPM for the traditional cohort and $5.00 PMPM down to $4.75 for the expanded cohort. So that is a revenue reduction to one care. Next, and importantly, those PMPM funds cannot be used to support one care operations. So the financial supports, clinical supports, quality data and analytics functions that we delivered to the providers in support of their success and their value-based programs, not an eligible expenditure for those revenue streams. Next, we have the care coordination outcomes payments. Medicaid agreed to fund base payments, but not bonus payments for practice specific outcomes. So recall in the care coordination program it now has really two parts, a base payment and then practices can earn a share of the bonus payments based on their specific outcomes and performance. Based on the result of negotiations, there will be no bonus payments related to the Medicaid outcomes, just the base. And lastly on this slide, the quality model. I spoke to the VBIF earlier, but to elaborate a little bit more, the original budget submission included an all-payer quality approach. This was in response to providers who often say to us, we don't treat our patients differently. If it's Medicaid or commercial, we treat them the same, which I can understand. So we've tried to develop programs that are a little bit less payer-specific and a little bit more all-payer. As a result of the negotiations though, there remains a separate Medicaid only $2 million value-based incentive fund pool that as I said before is paid from DEVA by DEVA directly to the provider. So it never flows through one care. We are going to remain as the administrative entity for the program, the quality evaluation, determined payment amounts and recipients, but those payments will be paid directly by DEVA. Shifting into some more numbers, this is a revenue slide. I'll note again, as I always do, the total cost of care targets are not really revenue, they represent accountability in these programs. So there's not always a cash flow through one care. We updated all of our total cost of care target estimates, the gross numbers, and those numbers are all the product of two things. It's attribution and our target estimate. So we've updated both accordingly where we were able. In total, the number is down a little bit by $13.9 million. However, we remain right in the ballpark of the $1.3 billion number that we presented earlier. So no big splashes or big news in that area, even though the numbers are larger, we've just updated our estimates accordingly. Also note that they do remain estimates because many of the targets will be updated at the conclusion of the performance year. The lower section of the table references revenues that actually do come through one care and support our work. The payer program support row, you'll see a reduction of about 1.5 million. That's directly related to the reduced PMPM funding from Medicaid as a result of negotiations. The reduction was actually offset a little bit by increased attribution, so that helped soften the blow a little bit. Other revenues line is really a timing related issue. We've had a number of deferred pools, primarily related to the value-based incentive fund. We've just updated our estimate or estimation of when the funds will be expensed. So there's more that we plan to expand in 2022 than we initially modeled or thought. And then the last row, hospital participation fees, they have increased by 927,000. There are a number of moving parts that affect that number ultimately at the end of the day, but a big driver was certainly the Medicaid PMPM reduction. Taking a look at expenses, you'll see at the top the corresponding health services spending of $1.3 billion. So I just consolidated that a little bit in this slide here. When we look at all the population health management expenditures in the middle section of the table, those of note include the complex care coordination program, a reduction of about 245,000. That's largely the Medicaid bonus payments that have been taken out. The CPR program is just a tune-up of attribution, no changes to the program design there. As we get down a little bit further into VBIF reinvestment and other material change, that's a timing issue that I spoke of before. When we expect those VBIF reinvestment expenditures to occur, we're anticipating more now in 2022 than we initially anticipated last fall. In the operating expense category, as we always do, we go back through everything and scrub. The notable changes are in the salary space, really two factors, namely any open positions and one care like many other organizations does struggle with open positions right now. So we've updated that. We also have a flip of some positions between salaries and consulting legal and purchase services, which is the third row. So you see some kind of offsetting increase to the decrease. In the software and informatics tool section, this is where you will find the extra 150,000 for the benchmarking tool. And in travel supplies and other, the main change there is actually related to the Green Bank Care Board billback. Between the time where we submitted the initial budget and the revision, we received our latest invoice. So we just updated to make sure that we were covered on the expense side. So note that the total operating expenses has been increased by 150,000. That amount is our current estimate for the benchmarking tool solution and was allowed for through the current writing of the budget order. I didn't put a bottom line on this slide, but just to note publicly that the bottom line remains $0. So no planned gain or loss in this revised budget. Next hospital participation fees. So I mentioned before that the number has increased by 927,000. The total hospital contributions are now 19,623,000. I've included the allocation by hospital here on this table. Generally the way this works in terms of process is once the total number is known, the 19.6 million, there is a policy that determines the allocation of that amount to the different hospitals participating in one care programs. There has been no change to that policy. So the same formula is used to divide the 19.6 million up amongst the providers, but we've showed the change between the initial and the revise for each particular hospital just as the way the cookie crumbled. Total risk and risk model. So despite all the updates that I mentioned around the total cost of care targets and attribution, which overall were actually pretty minor, the potential risk or loss remains almost unchanged. It's still 16.2 million. It's not exactly the same, but it's very, very close. So no substantial change in the downside potential. Upside potential is 17.5 million. Also no change there. There's one program that's upside only. That's why those two numbers don't match. I thought it'd be nice to mention just two other variables that we think about when evaluating the risk or the shared loss potential. First is continued extension of the federal public health emergency status. This has an impact on the Medicare program risk. So we monitor that closely throughout the year. Next is in Medicaid, if the redetermination process restarts in 2022, it could result in material attribution attrition. So many lives can be exempted from the program. If that happens, savings and loss potential could drop both sides, but we'll monitor that one as well. Wouldn't have any other big operational impacts or budget impacts generally speaking, but it wouldn't lower the overall savings and loss potential for providers. Aside from the updates noted, there are no other changes to the risk model in terms of how risk is apportioned amongst the providers participating in one care per month. Commercial fixed payments been hot topic lately, so I thought I'd spend a few minutes on it. I'm gonna start with some targets. Milestones might even be a better term for it in this particular context, but we submitted some targets in a previous related to last year's budget order, I believe, that where we outlined some goals or targets for getting greater fixed payment conversions in place across the one care network. What these numbers are is a percentage that as a numerator it's the amount of fixed payment relative to the total cost of care of accountability for the corresponding program. Our sphere of influence remains what we're contracted for with these payers. So we're looking at the total cost of care for any given program and in a relative way, how much of that has been converted to a fixed payment. When we think about fixed payments, there's often a lot of talk about reconciled versus unreconciled. For the purposes of this slide, if a fixed payment reconciles, I view it more as fever service that's truly not fixed. It's a cash flow mechanism, a lot like a PIP payment. So just to note, we do have a fixed payment program for Medicare, for example, but that reconciles back to fever service. So we're showing it as a zero. Somebody could debate that, but that is the perspective that we took for this particular slide. When we look at how 2022 panned out relative to the target submitted, really close. Medicaid in the middle came in a little bit higher than we anticipated. There's really no big change that occurred other than just refining the estimate and getting the actual results. So nothing terribly noteworthy there. Medicare and commercial, no big deviation from the expectation. I'd like to note though, there's a couple of different perspectives one can take on those particular numbers. It is true from the payer perspective, our contract with the payer that those amounts fully reconcile back to fever service. So upstream one care to payer fully reconciles. However, downstream when one care implements a fixed payment program under the CPR program, we don't reconcile that fixed payment with the CPR practices. The hospitals cover that reconciliation. So if you're looking at this through a provider perspective, truly those practices do have a fixed payment. So both are valid perspectives. We could go back and forth. I did in my head about which perspective was appropriate here. I just thought I'd put it down and then note it and we can talk about it as you like. We did not secure unreconciled fixed payments in our 2022 negotiations with commercial insurers. However, we continue to have discussions with them and there's a lot of work left, but we're really trying to get something up or at least take a step forward in 2023 where we can start to chip away and get closer to that target that we outlined previously. Other thing I'd like to note looking ahead a little bit is that you'll note in the very top table that we anticipated a significant jump in the Medicare fixed payment percentage from zero up to 53.4. This is or was based on our hope and target to have an unreconciled fixed payment with Medicare in 2023. At this point in time, we just haven't received signals, indications, or frankly a lot of hope that suggests that Medicare is ready to convert to a true fixed payment. So if I'm doing this exact same slide next year, at this point, I'd be predicting that there will be a variance in that particular area. And lastly, source of funds for PHM programs to address this one. For a number of years, we've been maintaining this behind the scene. It's really a mapping of revenue streams to our expenditures. We do this for not only to sound financial management, but also to ensure compliance with our contracts. It's complex. I'm trying to simplify it a little bit here, but generally speaking, PHM programs are funded through two main sources. The first is the payer contract revenues. So for example, when Medicaid pays us at PNPM, $4.75, those funds are used then downstream to fund these PHM initiatives. The other is hospital participation fees, so the hospital contributions. In some cases, perhaps most cases, there are multiple funding streams for any individual initiative. Usually this is broken down by, or a breakdown by the different payer line. So for example, in the basic $3.25 PNPM, we paid a primary care. Medicare doesn't contribute to that. So the hospitals fund the Medicare portion, but for the programs where we do receive a PNPM from the payers, their contributions may be allocated to this expense. So that's where you might get a particular program that has multiple funding sources behind the scenes. I'll mention there's a much more comprehensive table that doesn't really fit into a slide well in our submitted budget documents. And invite folks to go look there for more depth. It will show in more detail the different payer lines, their revenues and to which PHM expense they are assigned. And that is that I'm gonna stop sharing my screen and turn it back over to you, Chairman. Thank you, Tom. Thank you, Tom. We'll open it up to the board for questions or comments. I'll throw one question out there while the other board members are thinking. Tom, are the three of you and all the staff members at OneCare attributed lives? I actually don't know. It might be a PHI violation for us to actually look at that. So I'm not sure of the answer. And I'm not even sure if I can look that up, but we can find out. That would be helpful. I mean, on a conceptual level, we have a contract with Blue Cross Blue Shield and UVM Medical Center does have Blue Cross Blue Shield as its TPA. So you could make an assumption that we are attributed unless we opted out or didn't see our primary care physician. Vicki, were there any changes so that UVM is paying some costs directly rather than through Blue Cross? Not that I'm aware of. Was there something specific that you had heard or? Just the numbers don't look the same this year as last year. No, not that I'm aware of. Okay. Board members, questions or comments? I can go ahead first. Thank you, Robin. Sure. So Tom, on your slide about the complex care coordination program, and thank you for reminding us that it was a transition from being linked to care using Care Navigator to different performance measures. Could we just get a little more information about what those performance measures are? Sure thing. I'll take a stab at it first and anyone else from the team can elaborate. So through the process that really started last summer and then went trickle into the budget season, we separated the program into the different participant groups. So we have a primary care group, home health, DA, et cetera. And the goal was to find appropriate measures for each group that fit really their role within the health system. For primary care, we landed on a risk adjusted and truncated total cost of care indicator under the thinking that a primary care office that does really effective care coordination should be yielding favorable or positive risk adjusted total cost of care outcomes. For home health and our discussions with home health, what they often say to us is that what we can really help keep people out of the hospital, which I believe. So we set up the measure to look at the inpatient rate or frequency after somebody has engaged in home health services. So in other words, if inpatients are really low after home health services have begun, that is a good outcome. And then the designated agencies, the performance outcome and AAAs as well is primary care engagement where we're trying to ensure that those with seeking services to the designated agencies, whether for mental health, substance use disorder, whatever are connected with a primary care provider. I'll say personally, there's a lot of opportunity in that space. I came from the DA system, but 42 CFR handcuffs us quite a bit in terms of the performance measures. Thank you. Hold on just one second. So in terms of the VBIF quality model, so I understand that you have the two components, you have what I'll call the multi-payer VBIF and then you have the separate DIVA VBIF and you did a good job explaining that one of the key differences there is DIVA will be sending the payments, although you'll be reporting to them on who should be getting those payments. Are there other substantial differences in terms of how those programs are structured? So that's one question. And the second question is, I would assume that if someone is participating in all three programs, for example, that they would be eligible for VBIF dollars from both pots of money. And so could you validate that assumption? Yeah, I'll start by validating that last piece. So there's eligibility for payment across all payer lines. If you're participating in all programs, the program is still designed to be very similar. It's the same quality measures that folks are accountable for. It just happens to be segmented that we measure the Medicaid and determine a Medicaid payment separately from the others. Okay. And not to ask you to speak for DIVA, but I'm gonna ask you to speak for DIVA. Do you know why it was important for them that that program flows separately? And if you can't speak for them, that's fine. I just thought I would ask if that why of it came up in the discussion. I thank you for phrasing it that way. I'll speak for myself a little bit about it as I found it challenging where we're trying to move to a more kind of combined all payer perspective. And this felt like a little bit of a barrier to the improvement there, but I can't really speak for DIVA's perspective in that meeting. I think it's a good question to ask them. Okay. Thank you. In terms of the VBIF reinvestment dollars, so you had said that there's a change there because you're expecting there to be more reinvestment now than what you had initially budgeted. And can you just give us a little more color commentary on how does that come about? Like what sort of drives that kind of thing? Sure thing. So this is largely related to the VBIF, but often our VBIF, any contract language related to the VBIF said anything other than a 100% quality score, some amount was retained by one care to be reinvested into the future. So that's the origin story for many of the funds. And they actually kind of keep accumulating as every year goes on. So it's not like a static pool. We have found it hard to come up with really good uses of the fund, particularly during the pandemic. It hasn't been a primary focus of providers understandably and workforce challenges have actually been a barrier as well. So the increase in 2022 actually is a reflection of the fact that less was expended in 2021. So we're kind of pushing it out. I'll add to it and say, we're very engaged in a process right now to really look at the pools of funds and think about how we can put those to good use. Just from a financial management standpoint, I don't like having deferred money sitting around for too long and I want to use the funds well. So we'll likely have some really good updates for that in our budget submission this fall. Okay, yeah. So I just, and then a clarification on the commercial fixed payments. So what is included in that commercial calculation? It sounded like it could be the SVMC pilot and CPR. The numbers in the actual, it's a very small number, the 0.16% is just the CPR. I don't view the SVMC piece because the SVMC has to pay the difference back. Yeah, okay, okay. Got it. Got it. I think I will pause there. I have a couple of other questions but I want to make sure other people have a chance to ask some. Okay, questions from other board members? Sure, I'll hop in there. And again, this is a, thank you for the presentation. Thank you for the update. This is a similar question to Robin's. So I understand you may not be able to fully answer it but from your perspective, if you could share with us what you would know or understand to be Diva's rationale for their reduction in the PNPM funding for the elimination of the bonus payments, you know, unwillingness to cover admin. I guess I would love to understand what your understanding of their rationale is as a first part. And then what are the delivery system reform consequences of that reduction in funding in terms of the success of the initiatives that you have? It's hard for me to know the rationale, frankly. It's a challenge for us operationally. So I can probably jump into the next part of it. You know, this work doesn't have a natural funding source. Like there is no Medicare code for healthcare reform that we can build, right? So the funds need to be generated either by the healthcare participants themselves or through some sort of support mechanism, whether it's a payer or the state of Vermont, specifically that says, boy, there's some good opportunity here, let's put some resource behind it and make it effective. So when it comes to the delivery system and our abilities, the lack of any kind of financial support outside of the providers or dwindling financial support outside of the providers, but more fairly is a sustainability challenge for us. And you know, the hospital dues number is significant, something I think about a lot and I hear about it a lot too. And as we move forward, we are always thinking about how do we keep this good work going? And it really is good work and make it sustainable financially for the hospitals and everybody else participating. So it's kind of another headwind that we just constantly are facing while we're trying to do some really good work with our providers. And it's been interesting working with the state of the last few years. You guys can, you know all the stuff that's going on, but this is just how it manifests and what it does for us downstream is really kind of jeopardize our ability to keep investing and keep the money going into the right places in the health system. In terms of the, can you just help me understand how OneCare made up for the reduction in Medicaid admin funding? I recognize some of it was an increase on the hospital side, but can you just walk me through a little bit about the reductions from the Medicaid side, the increase in the hospital side and then what you did within the operational expenses to make sure that you could afford what you need to do? Sure thing, good question. So yes, if all is equal, if we just had the reduction in the DEVA PMPMs, that amount one for one would have been passed through the hop to the hospitals through the Purchase Mission Fees. There are a number of other moving parts. The one that has the biggest impact actually relates to attribution. Some of the payer lines come with a PMPM fund, Medicaid still does and the commercials do, Medicare doesn't. Because the increase in attribution was largely in Medicaid, which has a funding source that comes with it, it helps to offset the hospital dues expense. If the attribution increase was in the Medicare area, that would land right in the hospital participation fee math because the hospital have to pay all the PHM for the Medicare program because there is no other funding support. So that dynamic is what drives the variation between the specific DEVA line item reduction and that participation fee reduction. Operating expenses aside from the $150,000 for the benchmarking tool or net neutral, so that didn't really come into the equation other than that one amount. Great, thank you. One other, we're actually two quick other questions. On slide four, if maybe you can pull that up for a quick second, you'd be surprised if I didn't ask about evaluations, right? So I guess what I'm wondering a bit is a couple of things. One of the things that we've heard recently is HSA level data. It may not be as helpful as kind of practice level and facility level data in the sense that it doesn't really, it might contribute to the not me, not my problem. It's not my practice, it's not my facility. This could be coming from somewhere else, so I'm wondering if that has been something that you've considered going towards more variation in care rather than by doing it by HSA, doing it by practice level, having some of that data policy reports and applications related more specifically to the practice or facility level to in order to get more actionable data. And then the second part to that question is with the HSA consultations and the Utilization Management Committee, have you already found and can you identify examples that have been taken of concrete actions in terms of delivery system reformed from those consultations or the committee's work? So, it's kind of a two-part question. HSA level data, is that the appropriate data for actionable steps? And then as a result of the consultations and the Utilization Management Committee, what concrete steps have already been taken that you can identify? Sure, I'll take a stab at it. So regarding the HSA versus provider level, I think it's an and. I think we need to be doing both. And just to say it, like the practice level is very important and a lot of our reports get down to that practice level and try to benchmark an individual practice against peer groups. So for example, comparing an independent primary care practice to all the other independence within our network and similarly for FQHCs. So we're trying to get down to that level. But I do think the HSA perspective still remains relevant and valuable. When we survey the state, I view each HSA as its own little healthcare system for the community they serve. They all have different dynamics, every single one of them. There's no two of them have the same look and feel. They all have different dynamics in play. And I think it's important that they as a health community for their area understand their strengths and opportunities collectively. So if we're really trying to work to improve the healthcare system, the HSA perspective is pretty important to me, but it is an and. It's got to be married up with what any individual provider can do towards those goals. That's the first one. For the second one, I'd like to get back to you because I know there are some good outcomes in that space. These are newer processes though. So I'll mention that what we discussed just the last quarter with folks, I wouldn't expect them to be already demonstrating huge results plus our data will lag behind. What's been really cool to see though is when an HSA, their data looks great in domains like diabetes management, we asked them why. And often what they say is, this has been an area of focus for us for the last two or three years. We put some energy behind this. And it's pretty cool to see it bear fruit and actually show up. And credit's not to me or any, it's really to the work that the healthcare providers doing in this area. And we can see it through our data and then we can facilitate conversations with other providers. So that's the space we're trying to get into a little bit more as we hopefully get some stability in healthcare patterns because it's been harder the last few years. But really using these HSA consults, I identify areas of strength as much as opportunity and share those strengths. I guess I would ask that when the next budget comes around, if we could hear more about some of the results and some of the concrete actions from seasoned devbers. But it looks like Sarah has her hand raised. So not that I'm the chair here, but if Chair Mullen doesn't mind. Go for it. Thank you, Chair Mullen. I just wanted to add two comments to what Tom said. On the first question, I think the other reality that we need to mention is that a lot of the practice or site level data collection still requires manual processes. So OneCare has several FTEs that spend the majority of their time doing that manual data collection for quality, for example. And we're working really hard with the HIE and to try to maximize population health reporting out of EHRs, but there's still a long way to go. So I think there's a resource expense associated with that where we're trying to be really careful about what is the most valuable information. And to us, a lot of it's been in the quality space and aligned with that VBIF in the last year, year and a half. And then to your point, Board Member Holmes, around sharing some of that information, it's actually really timely at our board meeting on the 17th of May, we have an HSA coming to speak with our board in the public session about the consultations they've received from us and what actions they've taken as a result. And so that's coming out of the Bennington community. And our plan is to invite different communities roughly every quarter to share that information publicly. And we're working to figure out from more of an evaluation standpoint, how can we collect that systematically when it does change? And you can't quite aggregate it across those communities in the same way, but yet it is rich data and it will tell an important story about the focus and the impact that they're having in local communities. I'll just put a pitch in for, I would love it if it's possible to simply do a quick survey of the folks that you've worked with at these HSA consultations and just ask them even in qualitative terms, what, you know, how have you implemented or what steps have you taken as a result of some of the data? And if you had that even just in a simple, you know, survey prior to the next budget hearing, that would be wonderful because I think that would be a simple way to just get some of that information. And I recognize it's not a full-on survey but I'll just throw that out there it would be wonderful to hear how these have had impact. And my last question is about the FPP targets for commercial and I'm just wondering if the 24% and then higher than that for subsequent years is aspirational and, you know, specifically, you know, what are the confidence intervals you have around that and what are the obstacles that you see from one care Vermont's perspective to actually meeting those targets and what do you, have you heard the obstacles from the payer side to meeting those targets and how do we overcome those obstacles? Sure, good question. Oh, go ahead, Becky. I was gonna jump in just a little bit and I just wanna speak from one care's perspective and let the payers speak from their own, you know, challenges that they might have but from one care's perspective, there's a few really important variables into moving to a fixed perspective payment. One is that you have an actually sound target that your budget and agreement is based upon. So that's like step number one that you have to have in place. The second is that your FPP is tied and somehow relates to that overall target and is not reconciled at the end because we're really looking to have that predictability. I think one of the third things that we've seen in the commercial payer space is the speed in which they're able to deliver a perspective attribution of our attributed lives. Oftentimes that doesn't come until later on in the first quarter of the year. We're really looking to make an impact. That has to be something that we get closer to the beginning of the year or the end of the previous years to be able to start providing that data to our network so that they can take some action. And the last piece of it is to make sure that the claims that we're receiving from the payers is predictable year over year and that the integrity of those claims are good. So those are some of the challenges that we face in the past and that without those factors in place we can't reliably move to a fixed perspective payment with the payers. And then you have to get the payers to agree. So there's the last hurdle to jump over. So Tom, did I- Before you go on, let me just ask you what is the challenge with coming up with an actuarially fair fixed perspective payment? Agreed. Like you said, that was a challenge. If you could elaborate a bit on what the challenges are underneath that. I'll get simple and then maybe I'll let Tom give like a high level example but I would say that you need to have agreement from the two actuaries that it's a sound target and that it's something that the providers can actually impact. Like they have a reasonable ability to make a difference and achieve shared savings based on that target. And I think that there might be a difference and perspective on how that target should be created between our two actuarial teams. And is that different than the Medicare setting an actuarially fair target? What is the difference in the process that makes it more challenging for commercial than for Medicaid when you're doing the same thing? I can jump in. I think it's a different dynamic where there's two businesses essentially sitting across a negotiation table. That's very different the way the Medicare target comes to us. I mean, you guys set that trend rate and our job is to evaluate on our end. So it's a different dynamic. That's not a negotiation. It's not a negotiation, the Medicare model as much as it is in the commercial. If I said Medicare, I meant Medicaid, sorry. Oh, for Medicaid, sorry. Medicaid, what I really appreciate about that process, credit to Diva on this is they're very inclusive. They bring us to the table. They bring our actuaries to the table, their actuaries to the table. We talk about it together and reach agreement. It just works a little bit different in the commercial space. And we don't get the same modeling data. So there's data asymmetry there. And candidly, the results of the past are influencing the current dynamic where we're trying to build something that's really foundationally sound and then build out from there. So get the target right. Make sure that that is being set in an appropriate way to evaluate what the providers can affect. Again, we're not an insurance company. So what can the providers reasonably control? And then that paves the way for us to go bigger together in the fixed payment space. So that's really where we are right now. Great, thank you so much. I'm happy to pass that along, Chairman. Okay, other board members, comments or questions? I have a few. I want to follow up on Jess's discussion about the commercial partners. Oh, by the way, when I first started reading your amended budget, I was pleased that you were pretty much on target in the original budget and the revisions from a financial point of view, were pretty orderly and not chaotic. So a good job with that. I just want to emphasize kind of emphasize, and I'm sure you understand this, the importance of commercial FPP. In the last budget cycle or 2022, the amount of commercial payments to hospitals was 1.6 billion, and only 4.7 million of that was FPP. And that's probably true FPP, if my understanding is right, that this is associated with Southern Vermont Hospital and their project down there, which, as I understand it, is not reconciled. But it just, to me, there's a sense of urgency that at some point people get tired of something not happening. And so if hospitals are not on, if the commercial payers aren't on board, it just seems to me at some point, people will say, your biggest fish in the sea is inviting on the hook. And it's just not going to work in terms of accruing the kinds of savings and innovation that folks hope will come from FPP. And I'm just wondering what is your assessment that the differences between you can be reconciled in a near term? Yeah, good question. Just to clarify, the SBMC fixed payment does reconcile the commercial spaces to make that point. I have cautious optimism in that we're having some good discussions right now. And I think when I reflect back in the last, maybe nine months, we put a lot of emphasis with the commercial payers first around the target. And we did get some positive movement in that space. And that gives us encouraging feelings that we can build out from there. So I do have some positive feelings about where we're headed. I do think that we could get something up and running, but it's going to continue to take work over the next few months. So I hope that we have a little bit more solid footing when we go into the budget process in the fall about where we're heading with this. So I'll leave the board with a little bit of cautious optimism that we can get at least a step forward. What I'll caution is just in light of the past and some of the commercial relationships are newer too, we have to build out thoughtfully. I agree with your point at some point when it just keeps not showing up, people lose interest, I agree with that. And it can't be done rationally either because it does really matter. I take the cash flow very seriously with the providers. So we're working the process, trying to get a step forward and just building up from there. So hopefully in the fall we have something more concrete to share but we're going to continue to work and have the good discussions to see if we can find some program that's honestly a win-win for both sides. So my next question has to do with the evaluation contract with the UVM College of Medicine. And I'm just wondering if you can give us a little insight as to what are the key performance indicator gaps? Your slide referenced that the part of the contract was to identify gaps. And I'm just wondering do you kind of know the general nature of what these gap areas are? And that's not GAAP, it's GAP. Thank you for that clarity. I think part of it was let's try to get insight from other parties and have their research team look at what other ACOs are doing, what they've seen in their work to say, hey, one care you haven't brought up this. Maybe this should be within your sphere. So I don't really necessarily know what they are but it's always good in my view to get fresh eyes looking in that will be able to tell us. Yeah, you're missing this. This should be really core to your area of focus. And what is the value of that contract? Is it a big deal or is it, how much is that contract worth? It's, I wouldn't call it a big deal on the scope of the budget. I'm not sure I wanted to disclose in public how much they're charging us but it's not a terribly expensive engagement in the grand scheme of the world but I think it's a valuable one. I noticed on your balance sheet that the cash position for 22 revised over the approved went from $20 million down to $14.3 million. And I'm just wondering what's behind that? Sorry, let me, often in the cash projection in the balance sheet it's a timing thing, how much we expect to still have on the books that are either owed or not owed to participants. One of the changes that has occurred more recently is in the last few years that the Medicaid fixed payment used to come in December of the prior year and that amount would sit in our balance sheet as we crossed over from December to January. More recently that's been coming actually in January. I'm happy to supply like a simple reconciliation what that is but largely it's a timing related fact. So I mean, so I hear what you're saying is that it's a timing issue, not a material issue. Correct. Okay. And let's see if there's anything else here. So when we went through looking at the Medicaid's Medicare's relationship with Clover for their Medicare Advantage program, in their quality metrics that they had for measuring success or failure were patient satisfaction surveys. Two of the five metrics or quality metrics were patient satisfaction surveys. And so I'm just wondering if Medicare can do it, why can't we? If Medicare can do it with their Medicaid Advantage programs are the quality metrics that we're using similar to what is with the Medicare Advantage folks? Board member Pelham the quality measures themselves often vary, we certainly through all of our payer programs collect patient satisfaction data it's usually through something called a CAP survey. I think the challenge that we're seeing more in the benchmarking space is that there's not an entity out there that aggregates that in a way that you can then create comparisons. So that's the gap that we've seen when it comes to trying to think about how to make that actionable information. And what our network continues to do is in addition to those once a year surveys they collect more frequent surveys and use different types and they use that to inform the performance improvement activities that are going on at a local level. So Medicare was collecting this information from their Medicare Advantage relationships that is in the source for comparability for patient satisfaction. We have not found a vendor that aggregates that information and makes it available. Now that's not to say there's not anybody out there but we haven't uncovered it and the four or five vendors that we researched in extreme depth relative to the budget order made it clear that they do not do that. Okay so what you're saying is that there is the middle entity there to go to that Medicare collects its data and it sits at Medicare probably. To the best of our knowledge. Yeah okay well thank you I'm done. Thanks Tom. Other questions or comments from board members? I know that Robin you mentioned you might have a couple more. Yeah I have a couple actually it would be good to jump in now because it's related to the benchmarking. In the materials that you submitted around the vendor and the available benchmarking metrics one of the vendors did have two metrics in patient satisfaction and engagement and three in evidence-based practice. So it looks like I don't obviously we don't know what exactly those two and three are from the materials submitted but why wouldn't there be some utility in looking at those that if those are available from that vendor? I think there are a few that are available and we submitted more detail to the staff under confidentiality so that you can see that but if you were just to think about let's say appropriate use of MRI for a particular condition that's something that from claims data they could start to look at and it'll be part of the conversation that we do have with them over the next couple of months to then also work with the GMCB staff around what's available and what is meaningful under those key performance indicators. Our concern when we submitted the budget order is that globally when you talk about patient satisfaction and you talk about clinical appropriateness people tend to think that that is robust and that there's a lot of information there and our concern was that it could be an over signal of what's actually possible right now. I see, okay, yeah, all right, got it. Cause certainly I think from the material that was submitted those are the a couple of the domains where it is they are light I would say. So certainly not robust to your point. The other question I had is could you also speak a little bit more about once the benchmarking is in place how you might then use that information with your network? I'd be happy to speak to that. So what we are picturing is that there will be initially, ACO level benchmarking so one care to other ACOs nationally in the Medicare space and we are wanting to investigate how we can then use that benchmarking data to drive HSA level reporting. And so it was clear to us in conversations with our network that going into yet another independent system to go look up some numbers was not feasible. And so what we really chose to do as a solution is to think about how to get the meaningful data and then we will need to do some work to redesign some of our standard reports to be able to insert that benchmarking information. Now I think it is really interesting and important for the board to be aware that the vendor that we are currently negotiating with feels pretty strongly based on their many years of experience that annual benchmarking is the appropriate frequency with which to run those national benchmarks. Now certainly one cares comparative data can be done more frequently than that and should be but anything more than that they really felt like with produce noise rather than value. Thank you. Sorry I was muted. Thank you. That's all I had. Okay. Any other questions or comments from board members? If not, I'll open it up for public comment. Does any member of the public wish to offer comment at this time? Sam Pysh, Health Care Advocates office. Hi, thanks so much, Chair. And thanks, Tom, Sarah and Vicky for your presentation. This question kind of follows up or comment rather a bit of both. Falls on member Holmes question regarding evaluation which I think it'll surprise no one that I'm interested in. I'm wondering if we could hear a bit more about what One Care defines as actionable from potentially providing examples of that. And in regard to actionable like by whom would that be by One Care or by other entities like the state or the board? I'm just wondering if you could speak a bit more to that. Thanks. Thank you for the question. I'd be happy to address it, Sam. I think in terms of actionable, we're really focused on how to parse down the information in a way that it's meaningful for the particular audience. So a great example would be our movement away from reporting chronic disease management or immunization status at an HSA level but instead to report that at the individual site of care so that they understand where there might be opportunities and then to facilitate a conversation about well, what is it in the documentation process or the workflow or how you invite patients back to your office that maybe could be modified in order to improve whatever the particular metric is. In terms of where the level of action is, I think that's a fantastic question. We certainly use our clinical governance committees like our population health strategy committee to discuss results and to gather feedback around where those gaps and priorities should be focused. But ultimately our job is to share the information and meaningful pieces into the different parts of the delivery system because they're the ones on the ground who can take action on it. Thank you. Any other members of the public who wish to offer comment at this time? Walter Carpenter. Hi, Walter. Hey, Kevin, how are you? I'm doing well yourself. Oh, you know, hanging in there on this rainy day, getting my weekly fix of health care, you know? Yeah. Couldn't live without it, right? That's right. Yeah. What would I do without the GMCB? I live for it. Got a season pass. I'm sorry, Walter. Just fairly sorry about that. I could tell myself. You mean I don't have a life, Robin? One, I just have the board pretty much summed up my questions. So I won't repeat them, but I just have one question. We've had a barrage of figures and facts and slangs and acronyms and jargons and all that over the past hour. I want to know, has the access to health care and the health care improved for Vermonters in any meaningful way with all of these charts and graphs and these budget forecasts and these HSAs and PMPMs and whatever? Has the health care access to health care and the health care to Vermonters improved in any meaningful way? I notice I meet silence. Ricky, do you want to try to tackle that or? Did you say me, Chair Mullen? Sorry. Yes. I wasn't sure if the question was being directed to the board or to one care, so that's why I didn't answer. Everyone. Even the public. Walter, I would say that the best indicator we have is the NORC evaluation that came out of the University of Chicago that really did measure the effects of the all payer model at large, which include the state and ACO interventions at looking at both cost and quality and opportunities for improvement. So that's what I would use to say that there is from that evaluation standpoint progress. Okay, other public comment? I'm going to turn to Cynthia Browning. Thank you, Chair Mullen. Can you hear me? We can. I actually have comment about last meeting board meeting. If that's not appropriate, I can send an email, but I didn't know what you were turning to next. Yeah, this is really the topic for this afternoon, but we're happy to take your public comment now if you would like to. Okay, it's just an idea and it's a raw idea, but in terms of the question of inpatient psychiatric treatment capacity, and I understand the tension and the question of the balance between community care and inpatient treatment. But to the extent that we need more inpatient treatment capacity and the financing is an issue, I just wanted to point out that for drinking water and clean water, the state uses revolving loan funds. And in some cases, the entity, which could be a municipality or could be a private entity, sometimes they get the loan at low interest or zero interest, or it can even become negative interest so that in effect, it's a partial grant. So I'm kind of imagining a healthcare investment revolving loan fund that if certain performance criteria are met could become a partial grant to an entity that was making investments in needed treatment capacity. So I know that completely beyond the ability of the Green Mountain Care Board to do anything with, but I just wanted to point out the possibility that there might be creative financing mechanisms that may not have been employed in this area, particularly given the state's substantial interest in achieving this kind of treatment capacity. So I just think it would be interesting to look into the possibility of revolving loan funds for investments in healthcare capacity, particularly psychiatric. So I'll leave it there. Thank you. I think it's a great idea. Do you have a few hundred million that you could kick it off with? Yeah, yeah, I'll look around for that in my sermon. But you would need to do that. You would have to find funding, but once it's funded, it gets partial repayment and then you kind of keep going. So it might be worth looking at what happens with drinking water and clean water. That gets federal funding too. It's just an idea. Yeah, I'm not sure and maybe Robin, you know, but isn't that affiliated with the rural development federal dollars? I do not know. Okay. There's federal money that comes through for drinking water and clean water and it's combined with state money and it's a very complicated area, but the basic principle just seems to me to be interesting because it would be a way to match private, you know, nonprofit funding being invested in a way that could be, the funding could eventually be discounted. I mean, you don't pay back the whole loan if you meet certain performance criteria. And I just think that might be a way to make a hospital more comfortable making some of these investments. But I'll try to do some research on it. I just wanted to throw it out there in case it might have any use. Thank you. Well, we appreciate your interest. Certainly it's pretty hard keeping a straight face when you say that mental health and physical health are in parity when I don't think we have anywhere as near the investment in mental health that we have in physical health. That's right. Just my observation. That's right. And this would be a way to jumpstart that, I think. Yep. Okay, Dale Hackett. Yeah, I'd just like to know more. I couldn't help but think as I was listening and like PMPM went down and I get at the, what you don't have funds for, you can't pay for. At the same time, it seemed like I heard many things that suggest we're going backwards financially forward. What exactly are the feds thinking? I mean, I heard several times they want Medicaid to stay separate from one care and what they're doing. And I just couldn't help but think at times like what is the goal of the federal government and did they express concerns about, we don't have the workforce, did they express concerns about, yeah, we know you need more money than this. Can you give me any background on what are they thinking? So you're asking us to speak on behalf of the federal government. And of course there's many, many layers of the federal government, but in the conversations that we've had with our contacts at the Innovation Center, they are hearing it from others across the country that workforce needs further investment. Clearly they've signaled that they would like to see to move away from fee-for-service to more value-based care. And other than that, I think you could ask 20 different federal officials and probably get 20 different answers, just like you could if you asked 20 different state officials. Yeah, I kind of thought that was gonna be the answer. But I thought I'd throw out the question and maybe something enlightening would come out of it. Okay, it seems like we move forward sometimes and then other times it seems like the very same steps we're taking to move forward is another piece of the puzzle that we actually move it backwards. And I just find that frustrating. Thanks. Well, I think Dale on the federal level, just like on the state level, the pandemic took everybody's resources and everybody's attention and time. And I think now they're starting to refocus back on reform efforts that could make meaningful changes in the future. But the reality is that everyone was laser focused on meeting the needs of today during the early stages of the pandemic rather than focusing on the future, just to make sure we had a future. And that was the right focus. Vicki, your hand is up. Yes, Chair Mullen, I just wanted to add for Dale if it was of interest to him is that CMMI did put out a strategic refresh paper laying out their plans and pass for the next 10 years. And that's available publicly online if the board doesn't have access to it. And Dale, you wish to have them happy to supply that. By all means, I would because one of the things that I get concerned about is and that 10 year plan should be a plan about how to deal with the pandemic and the effects of it over the next 10 years because there are going to be effects that will be around for the next 10 years or longer in healthcare from the pandemic. You can't go back to business as usual, the pandemic is going to show you that this did more damage than just a two-year cycle. It's like mental health. I mean, you've got kids that in school were so affected that's long-term, real long-term. Vicki, that's where I'm going. So yes, I'd very much like to see that. Thank you. Thank you, Dale. And you made me quickly check to see what the Fed did at the two o'clock hour. And it looks like it was 50 basis points. Hopefully the federal government can get inflation under control because that benefits everyone, including our hospitals. Good point. Okay, other public comment. Other public comment. If not, Marissa, I don't believe there's any action required, but help me if I miss something. No, you're correct, Chairman. There's no action required today. We will take up the amendment request next week at the moment that's the only thing on the table. Okay. Well, thank you, Tom, Vicki, Sarah. We learned a lot this afternoon. And with that board, is there any new business to come, excuse me, any old business to come before the board? Hearing none, is there any new business to come before the board? Hearing none, is there a motion to adjourn? So moved. Second. It's been moved and seconded to adjourn. All those in favor of the motion, please signify it by saying aye. Aye. Aye. Anyone opposed, signify it by saying nay. Thank you, everyone.