 Good afternoon and welcome to the Green Mountain care board meeting. My name is Kevin Mullin the chair of the board and I'll call this meeting to order. The first item on the agenda is the executive director's report Susan Barrett. Oh Mr. Chair the first thing I'd like to do is I'd like to announce a change to today's agenda. We will be removing the agenda item of the 2021 update to the 2018 to 2022 health information exchange strategic plan and 2022 connectivity criteria with the Green Mountain care board staff recommendations and a potential vote. So we're taking that off of the agenda and that will be put on the agenda later this month. Any questions on that or we're good. We're good. Okay the next item is I wanted to announce to the board and to the public that the the Green Mountain care board has received an extension for the Act 159 section for sustainability reporting hospital sustainability reporting. As everyone knows the hospitals are are under immense pressure from COVID from workforce issues from deferred care issues. So we talked with the legislature the chairs of the health health care committee as well as the Senate health and welfare committee and they've extended an extension to us until February 1st of 2022 for that reporting. Are there any questions regarding that announcement. Just a quick question in light of all that's happening obviously with COVID and the incredible strain on our system and with this additional time does it make sense then to move our December 15th discussion of sustainability planning into January. It does. We can make that happen. I think that makes sense. Absolutely. I agree. I think it's given everything that's going on. It does make sense to push it to me as well. Okay we will update the monthly agenda to reflect that information. Thank you all. I do just want to announce that we have two ongoing special public comment periods. The one care Vermont FY 22 budget and certification. We have staff recommendations will be presented next week. So we're asking that public comment be submitted by today to be considered ahead of that presentation or by December 17th to be considered ahead of the potential Green Mountain Cure vote on the budget which is tentatively scheduled for December 22nd 2021. And then as I've mentioned several other times we have an ongoing public comment period regarding a subsequent all-payer model agreement. And that is information that we can share with our partners on on this agreement. Ian Backus who's here with us today at AHS as well as the governor's office as they're taking the lead on a potential subsequent agreement. And that is all I have to share today. I will turn it back to you chairmellon. Thank you Susan. The next item on the agenda are the minutes of Monday November 22nd. Is there a motion. So moved. It's been moved and seconded to approve the minutes of Monday November 22nd without any additions deletions or corrections. Is there any discussion. Hearing none. All those in favor of the motion please signify by saying aye. Aye. Any opposed signify by saying nay. Let the record show that the minutes were approved unanimously. And as everyone heard from Susan the agenda for today has changed and we will not be taking up the HIE strategic planning connectivity. So at this point I'm going to turn the meeting over to Sarah Kinsler who will tee up the discussion for the all-payer model discussions. Thank you Mr. Chair for the record this is Sarah Kinsler GMCB Director of Health Systems Policy and I'm joined by Ina Backus. And Ina actually is going to introduce us but I will I will get the materials projected on the screen while she does that. Good afternoon everyone and thank you for having us for this discussion this afternoon. As the board is aware Vermont is required by the all-payer accountable care organization model agreement to submit a proposal for a subsequent agreement by the end of performance year 4 which is the end of 2021. We're here today to recommend that Vermont propose a one-year extension of the current agreement with some key modifications that reflect the implementation improvement plan that was published last year. These modifications would include the inclusion of fixed perspective payments made by Medicare in the all-payer model agreement. Just like our Medicaid program makes fixed perspective payments we would like to propose that Medicare in a one-year extension make fixed perspective payments and provide specific guidance to critical access hospitals about how to participate in such a payment model in the prospective payment model. As a part of the extension proposal we would also like a key modification to include decoupling the Medicare investment in the blueprint for health and support and services at home program from the ACO benchmark. Instead of running the investment through the ACO where it interacts with risk corridors these dollars would run directly to the state of Vermont to allocate to these important population health improvement programs. A one-year extension will maintain the current performance framework for the all-payer model agreement. However the modifications I just mentioned are quite significant. Our implementation improvement plan was clear that more provider payments should be converting to fixed perspective payments instead of remaining fee for service and I know that that's been a focus of this board's discussions as well. This one-year extension will allow the state to more fully engage with providers, payers, advocates and Vermonters in developing a proposal for a longer term agreement renewal which would likely have a more typical time span of five years or six years as our current agreement includes. The opportunity for this type of engagement has been limited by COVID-19. As we pursue a longer term agreement beyond the one-year extension we want to think creatively about how to maximize Medicare's participation in value-based payment and in fixed perspective payment models and while our work with the Innovation Center does focus on how Medicare specifically can participate in state-based models we're also very focused on how to improve commercial payer participation in a longer term renewal. We're proposing the one-year extension to run through the end of 2023. We won't be proposing one-year extensions on an annual basis. This is not a proposal where we'll just look to make another one-year extension proposal. Again, we would be working towards a longer term renewal proposal for a more typical span of time. And today with this proposal we're looking for the board's endorsement to move forward in proposing a longer, excuse me, a one-year extension to CMMI. With this proposal we know that there will be an ensuing negotiation and that we will have to work with CMMI to arrive at what would be a potential final agreement for a longer term, excuse me, for a one-year extension. Now I'm going to turn it over to Sarah to walk through the proposal cover letter. Thank you so much. I'll join you at key points. Thank you, Ina. Thank you very much. So just to reiterate what Ina's kind of last point, this proposal that we are not before the board today to request approval of a one-year extension that we have negotiated, we are asking the board to endorse starting this process. So to put it in the simplest terms, the board and the public will both have another riot at the Apple in the event that we do propose, we do request a one-year extension and we do have those negotiations with CMMI. This will not be the last time that we are before you talking about this issue. We would be back with negotiated language which we would expect the board and the public to provide feedback on and eventually to request a board vote on that. So now I will walk us through the cover letter that staff have drafted, staff from the agency as well as board staff which we are proposing to send to CMMI to request this. So the first section of the letter really reiterates the points that Ina has already made about why we would seek a one-year extension rather than proposing a longer term subsequent agreement at this point. I will not read this out loud to you, nor will I go into depth on these, but we want to build on the things that we have learned and the things that we have learned based on the national experience as well to date. We want to ensure that we can thoroughly engage all stakeholders including payers, providers, advocates or monitors in developing a subsequent agreement proposal and COVID-19 has made that particularly challenging, especially for providers. And in addition, we have not been able to fully test the current model in 2020 and 2021 due to the COVID-19 public health emergency. So we believe that an additional year would allow us to more completely finish that test, noting that of course COVID-19 has not gone away or ended and will continue to impact the model and the way that we measure and evaluate the model. So in the materials which I believe are either posted or are about to be posted on our website and my apologies to the board and the public that you may not have these at your fingertips at the moment, we have included both this draft kind of proposed cover letter as well as a red line of the actual all-pair model agreement so that the board and the public and CMMI frankly can more easily see the specific changes we are proposing and the language that we are proposing with the red line that we have posted is in kind of the abridged legislative format. So it really focuses only on the areas in which we are proposing changes. And unless the board has any questions about kind of the introductory section, I will move on to describing the changes. All right, hearing none. Okay, thank you. Hearing none, the we have split the revisions into or the kind of proposal into three sections. The first are technical revisions. Those are updates to reflect the proposed extension year. So changing dates and performance years throughout as well as updates to targets. And the approach that we have taken is extending all of the performance year five targets out to a performance year six. So rather than kind of creating new targets or negotiating new targets, we're just recommending to extend and that goes for total cost of care, scale and quality and population health. Next, we have proposed technical revisions to reflect the amendment that had been negotiated between CMMI and the state of Vermont in 2019 to update quality measure specifications to reflect updates to national measure sets and to adjust some reporting deadlines to allow for more complete data and kind of reflect the reality of when we are able to produce reports based on data availability. These amendments went so far as to be approved by the board but they were never executed because this happened directly before the COVID-19 public health emergency. So these were amendments that were fully ready to go that we were never able to get signed because obviously our collective priorities shifted. Third, we have included some updates to language around Medicare payment programs to reflect that new Medicare payment models have become available in the time since the agreement was negotiated and signed. And also to note that CMMI is kind of phasing out the next generation ACL model as they continue to evolve their payment models. So we didn't want to have the agreement language tied to a program that was no longer active. The next generation ACL model was kind of the new the new big path that CMMI was taking at the time that the agreement was negotiated. But at this point, you know, we have collectively evolved. So those are the technical revisions that we have proposed unless there are questions related to the technical revisions. I won't move on to reporting hearing none. So there are three changes that we are proposing here. First, we are proposing to eliminate future payer differential reports. And this is because there have been changes to the process for developing the annual Medicare ACL total cost of care benchmark because of COVID-19. And the fact that we have used retrospective benchmarks for some years and that the benchmark process has changed just makes these reports significantly less useful. And so we have proposed to discontinue those. Secondly, we've proposed to reduce the number of remaining total cost of care reports to semiannual rather than producing them quarterly because the quarterly reports have had limited utility. And finally, we've proposed to eliminate the report related to Medicaid behavioral health and long-term services and supports and integrating that into total cost of care. And I'll let you speak a little bit more about that. In past discussions, including a town hall public forum meeting, we shared that it does not make sense to consider the inclusion of these Medicaid services for a limited extension of the current agreement rather it would make sense to consider these in alignment with any development of a proposal for a subsequent agreement and that these things be taken together particularly because a proposal for a subsequent agreement would likely feature different targets than we have today or potentially different targets than we have today. And so it makes sense to think about those two things together. Thank you, Ina. Any questions about the reporting changes that are proposed? All right, and finally, we've got a bucket which we are calling other changes but some of these are some of them the bigger ticket items actually, I think. So firstly, as Ina mentioned, there's a strong desire in the provider community for an unreconciled FPP payment model within the Vermont Medicare ACO initiative and the goals of the proposed changes are to indicate a collective commitment among Vermont and the federal signatories to design and offer an unreconciled FPP payment option in year six. The second bullet relates to the blueprint and SASH funding which Ina had also mentioned in her introduction. This proposes to move funding from an advanced shared savings model to likely a single source funding opportunity for the agency of human services. This is also how blueprint funds were moved from the federal government to the state in 2017, the first year of the model. And the goal here is really to preserve the current and historical federal investment in the blueprint and SASH with a reasonable annual growth rate while simplifying the flow of funds and kind of moving that out of the very complicated Medicare ACO initiative benchmark and shared savings and losses calculations. The third bullet is related to guidance for critical access hospitals, which Ina also touched on. We continue to seek further clarification and guidance related to participation by critical access hospitals in fixed prospective payment models including unreconciled fixed prospective payment models and how that could potentially impact their cost reports and Medicare reimbursement model. So that is also something that we have included in our red line. And then lastly, finally we propose to extend the waiver of scale target enforcement through the extension year that we received in a letter I believe in November or October. And we've done this by proposing to remove failure to achieve scale targets as a triggering event in sections six and 21 of the agreement. The state does not propose to change any of the reporting requirements included in the agreement and we would continue to report on scale as it is defined in the agreement as well as reporting alternative measures of scale that Green Mountain care board staff have developed and would be reported in performance year three which we think provides some more valuable information or additional valuable information I should say about the statewide scope of the model. That said, we just don't think that it makes sense to alter the targets at this point in the agreement or feel that that's productive. So rather than proposing to change the targets to something that we and the federal government agree are achievable, we would just like to continue to report and seek to make progress in that area. And those are the those are the proposed changes. And finally we've included a suggested timeline for the extension below which kind of compares the the current agreement to the suggested extension timeline. And that is all. Kevin I believe you're muted. Great questions for Sarah or Ina. This is Robin. I don't have a question but I do have a couple of thoughts that I'd like to share but I can hold it if you'd rather take questions first. No go ahead Robin. Okay great. I just wanted to say I I don't I personally don't see an alternative to requesting an extension just given the bandwidth necessary to focus on COVID-19 and AHS's necessary need to be really laser focused on all of the issues related to COVID-19. I think I personally would rather see something very simple as described here in an extension and really then allow our collective resources to be focused on what does the next agreement look like. I think trying to do too much while we're still in the middle of a pandemic will just not be productive or move us forward. I also like the approach of just living with the targets. We all know there are some major challenges with the scale targets but I can't emphasize enough having been through this before that renegotiating those targets is not quick or easy and and I don't quite frankly think it's worth the effort at this stage. We should just live with it knowing that there are problems with them and then we can focus our energies on what makes sense in terms of targets in the next agreement. I also think that you know certainly I think that we have heard in the past some public comment that appears to link the idea that if we were to pull out of the all-pair model that ACOs in Vermont would go away. I don't believe that that is the case. I think that's a misperception. I think the all-pair model allows Vermont to have the ability to work with Medicare to ensure that there's alignment between Medicare and our other healthcare reform initiatives in the state. Absent an agreement like we Maryland and Pennsylvania have with the feds we would certainly see I think additional Medicare only ACOs that are either region regional or national in scope coming into the state and certainly those there's no way for the state to prohibit that since Medicare is a national program. So I just wanted to make those comments about the extension. I think it's a good way to move forward and I'd like the approach of focusing on a couple of key things that we collectively recognize are important like the Medicare participation in unrecognized fixed payments and ensuring that the the blueprint and SASH dollars continue to support or continue to be supported from Medicare. So those were my comments. And thank you everyone for your work. Thank you Robin. Are there other board comments or questions. Yeah I have I think one quick one. I'm just in any situation like this there's two sides of the table where people we're presenting our ideas and things that we want to get done. And I'm just wondering if Eno or Sarah or any of the folks engaged here have any sense of any headwinds that we might hit at CMMI on any of these technical reporting or other issues that we're going to be presenting them. I don't I don't know of anything where we think we will get significant pushback CMMI at a staff level obviously has indicated to us at a staff level that this is something that they are very open to and that they think in particular given given the demands of COVID-19 on all parties is likely a I think a good path forward obviously none of that is committing any of the signatories to anything but that's kind of been the staff level consideration. I don't believe that any of the any of the areas that we've listed here will get significant pushback. Eno do you disagree. I don't disagree regarding pushback. I do think that it is important for us certainly in regards to the payment change to understand that the payment change is a significant undertaking for Medicare and that it does have technical aspects that are beyond the direct control of CMMI. And so they're in that regard again I don't expect pushback but I do think it's important that we are realistic that that is a very significant ask one that I think CMMI would like to explore with us but it has not been done before so I think we need to be realistic that we're trailblazing here. That's absolutely right. And I you know our experience with the prior negotiation and kind of implementation of our our current agreement suggested that the timeline for operationalizing major Medicare payment changes can be about 18 months. So so we know that this is challenging and while we are hopeful that this will will not take that long and that we'll be able to make significant progress there there are real barriers to you know to to to to changing changing the course of this this very big shift. So we will be working you know closely across the two agencies and with our federal partners to assess where where there may be issues. We are in a much better position to request this kind of a change because we do operate and have an agreement for the Vermont Medicare ACO initiative which you're very familiar with and that does advantage us significantly in making a request like this. One reason I ask that question is that I think during the hearing with the ACO the question was asked if CMMI were to approve unrecognized unrecognized payments today it would take about five months just to implement the mechanics of it. And so that kind of pushes us you know down the road where we don't even have that approval yet. And I asked the question to make certain that people's expectations aren't that all of this is going to happen in this intramur because it from just from a mechanical point of view and I think Sarah was making this point it can happen. The approval might happen but getting it up and running not so easy. Okay other board comments or questions. Yeah I just have a thank you for the hard work here and my question I guess revolves around a little bit of the timeline understanding that timeline a little bit more. The timeline for negotiation of this proposal how long does that take and then assuming that this proposal or some version of this proposal is accepted by CMMI and we do have the one year extension when given how long it takes to plan, engage stakeholders and negotiate a subsequent agreement when does that next planning start and what does that look like if you have thought about that at all. Just trying to understand the timelines here. And Sarah please jump in if you see otherwise I think we would like to see an expedited exchange with CMMI regarding the proposal for the one year extension so that we would negotiate on that proposal as in the very near term once it is submitted and hopefully bring that to conclusion with an agreed upon one year extension as soon as possible prior to the end of the current agreement term. I would like to see that happen significantly before the agreement term ends at the end of 22. With regard to the longer term a longer term proposal I think that we would like to be engaging on that soon with the board as well as with the public and my expectation is for that to be occurring in early 22 upon the new year. Okay great thank you. And this is something that I regretfully fully support and the reason why I regretfully fully support this proposal is that if I was able to not support it it would mean that we would not be overrun in our hospitals with COVID cases and ICU capacity problems and things like that but this is the reality where we had all hoped when the pandemic started that it would not have lasted as long as it has. And now I think we all know that we're gonna be living with this for a very long period of time and we have made great progress and that's due to our healthcare professionals who have done an amazing job and I think we have to be respectful and realize that they can't be at the table right now they have to be taking care of remoners. And so with that I fully support asking for an extension of the existing agreement. Sarah were you gonna present anything else or should I open it up for public comment? We were not planning to present anything else. The changes summarized in this cover letter really are fully reflective of all of the changes that we have included in the red line which by the way is now posted on our website and thank you to Kara who posted it and again Apologies that was not posted in advance but this really is comprehensive. So we do not have any other planned presentation. So anyone can go to the website and look at the red line agreement probably easier to follow it in the cover letter but the red line agreement will show the changes from the existing agreement. And so anyone who wishes to look at that and provide us with comment may do so but at this point I'm gonna open it up for public comment and see a hand raised from Susan Eranoff. Susan. Hi everyone, good afternoon. First of all, Ian and Sarah thank you so much for such a clear presentation and for posting the materials. I look forward to looking at them and of course I was really glad to see the Medicaid funded long-term services and supports issue addressed because that's just been hanging out there and so unresolved is to cause a lot of uncertainty in the long-term services world. My question has to do with Medicare Advantage plans and if and how that's gonna figure into the one-year extension and so request and so I haven't looked at the specific red lining. My understanding and please correct me if I'm wrong is that Ramoners with Medicare Advantage plans are not countable in the denominator are not attributable currently for the Medicare shared savings ACO. Can you correct me and then talk about I sure you guys heard Vicki loners testimony that somehow Medicare Advantage plan people are gonna be considered in value-based plans for purposes of scale. Could you talk about that and if that's addressed at all in the one-year extension? Thank you. Thank you for your comment. I was looking quickly to see if Sarah Lindberg was on but I'm not sure if she is. Are you prepared to answer that? I do think I can answer that or at least I can partially answer and also kick the can a little bit to next week's ACO budget staff presentation. I can see she's on so if you need to phone a friend, Sarah Lindberg is there. I always love to phone a friend when that friend is Sarah Lindberg. So Sarah please jump in if you think I'm getting it wrong and I believe Michelle DeGree is also on the line and I know that she will correct me if I am wrong in any way about scale. So thank you Sue for your comment and for your question. On the first issue of you know how and whether Medicare Advantage members are attributable Medicare advanced folks with Medicare Advantage plans are considered part of the commercial population rather than the Medicare population for the purposes of all-payer model scale. So rather than counting toward Medicare scale if they were attributed they would count toward all-payer scale. They're not included in the denominator for Medicare scale. They're included in the denominator for all-payer scale. That said, they're currently not attributed because no Medicare Advantage plan has a payer contract with one care. So were a Medicare Advantage plan to contract with one care they would potentially be attributed you know based on whatever the attribution methodology was for that program as defined in you know that hypothetical contract. So there's some there are some steps that I think would likely need to happen in advance. I in terms of whether Medicare Advantage is a value-based contract I think we'll talk a little bit about more about Medicare Advantage and the potential role of Medicare Advantage and scale at next week's ACO you know one care Vermont FY22 ACO budget and certification staff presentation. So I think I will I'll take the can a little bit if that's all right. And Susan Aronoff I'm really glad you brought up that because I think all Vermonters are tired of seeing ad after ad for different Medicare Advantage plans disguised as ads for providing people more and more. And I think most of us on the board have some concerns about Medicare Advantage and all those ads are just one more example of money that isn't going to direct care of a patient but there seems to be plenty of money to be made in the Medicare Advantage market. And so that's why we're seeing all those dollars being spent. And I know that many people are very high on Medicare Advantage plans and I think they do have a useful purpose for a number of seniors. But I also have grave concerns. So. Yeah I share your concerns Mr. Chair. I think one thing that's happening in the field is a lot of confusion for consumers as to what their choices are and what the implications of those choices are. And so you know it's a pretty vulnerable population people don't always like that word but I see it as a pretty vulnerable population. So anyway I think any clarification as to where those plans are fitting in our whole healthcare landscape in Vermont would be helpful going forward. Because I think the uptake has been far greater than what people had anticipated at the beginning of the whole process. And I remember specifically asking about it at different times and getting the response including from Sarah Lindbergh that we didn't expect the uptake of Medicare Advantage to be great in Vermont. But wow the number of options just keeps the mush for me. So. I can say that as a son of parents that are seniors it's next to impossible to figure it all out. It's very very frustrating. So next I'll call on Jeff Teeman. Thank you Mr. Chairman. I appreciate it. I'm Jeff Teeman with the Hospital Association. First I want to start Kevin by thanking the Green Mountain Care Board for the beginning of this conversation in deciding to postpone the next sustainability discussion until January. I think as you've readily acknowledged today in a helpful way hospitals are once again very much in the thick of it. So focusing on the most urgent priorities is helpful for everyone and it's good for Vermonters. So thank you for that. I do want to make a comment to connect the reform work with the kind of long term outlook for our health care system and also more immediately to the situation and challenges you described a little bit and that we're facing on the ground as we speak. I also want to echo your thanks to Sarah and Ina and everyone who is involved including hospital CFOs in developing the bridge agreement proposal and that at the Hospital Association we very much agree with the process that's been outlined here. So you know whether it's for a short period of time or for a long term kind of agreement extension I think any future iteration of the model has to ensure that the provider community can deliver the high quality care that patients expect and and also continue to be a resource to communities which have grown in their expectations of hospitals quite a bit in the past 22 months. So I think as the model evolves and it moves into the next iterations it should recognize and I think you've alluded to this that things have changed dramatically since we started this work. So who knew that we would get hit with a two year global pandemic that continues to throw us curveballs even right now or that we would face skyrocketing and unsustainable labor costs with no end in sight. Who could have foreseen that our workforce shortage would become so bad so severe that staffing our most critical beds would be a daily challenge. Who thought that our hospitals would be so full some days that transferring to another facility would take hours and hours and dozens of dozens of phone calls to hospitals as far away as Connecticut. And finally who would have guessed in forming the first all pair model that hospitals would be in the inoculation and the testing business and the public health arena and that they'd have to manage COVID outbreaks and vaccine mandates and supply chain shortages all while trying to pay enough to keep their staff and meet growing patient need. So I think to pivot where we are today as you said Kevin we have a record number of COVID hospitalizations at 85. We have a small number of open ICU beds at any given time. Right now eight hospitals are reporting critical staffing shortages including the Brattleboro Retreat. And to manage all of this hospitals are taking a lot of steps. There's a press conference going on right now where UVMMC is describing its effort to add ICU capacity similar efforts are underway at Northwestern Southwestern and CVMC. Other hospitals are adding or staffing up step down capacity so we can improve throughput through the system. And you also know that hospitals some are suspending or postponing elective procedures which does jeopardize access but is a daily consideration that hospitals have to make at this point. And finally they're working hard to discharge patients to the right level of care whether that's a skilled nursing facility or a psychiatric care facility or their home. And in all of those efforts I just really need to say that we appreciate so much the support of AHS and Secretary Smith and his team for all of these efforts the partnership between hospitals and the state continues to be invaluable on that front. So to conclude going forward I think to manage all of these variables and continue to invest in value based reform and care the model needs to ensure that hospitals have the financial strength and staying power they need to do that and to be there for the long haul. So appreciate GMCB's awareness of everything that's going on and the connection to our long term reform path and that we properly resource the system going forward. Thanks so much as always. Thank you Jeff. Next I'm going to call on Walter Carpenter. Walter. Thanks Kevin. I just Susan asked kind of the question I was thinking of so I just wanted to reiterate that say thanks and also thanks to Kevin for his comments on the Medicare Advantage plans. I think you could simply call them welfare for insurance companies corporate welfare. And but anyway you're dead on right about those advertisements and I hear that all the time too. And all the confusion and the plans and that that they they don't even when you get sick that's when you find out what's going on with those plans. The direct contracting agencies as well we should look at get rid of them. But the thanks for that I still I want to ask an overall question that was summed up in a sentence in the public comments about when we submit for the extension or whatever is exactly what kind of value have Vermonters gut out of one care so far. I'm paraphrasing that sentence. It was by a guy named a doctor named Dick Dundas. But I think that's a question we should ask in whether it's a one year extension or whatever. That's all I got Kevin. Thank you so much Walter. We're on the same page with the Advantage plans. You and me and share a lot of others. I think a lot of others. Okay is there other public comment. Is there any other public comment. So Sarah do you need an official vote that's just an endorsement or the fact that people seem to be supportive is that sufficient enough to move forward to the finalization of negotiations. That is a great question. I believe it's probably a question for Michael Barber. We do have votes noticed for you know potential votes noticed for both the 15th and the 22nd. Hearing that you know it sounds like the board is doesn't have major concerns. It seems like if we do need to have a vote it may make sense to do that on the 15th and and and have a public comment period probably open until the 13th so that whatever comment we received by that point can be summarized and presented at that time. If that's useful. All right. So I want to thank you and I want to especially thank Ina I know that you're going through some challenging times. Your plate is very very full and certainly this uptick in in hospitalizations isn't helping anybody at AHS to clear their plates to get other things accomplished. So thank you for that and with that I'll ask if there is any old business to come before the board. Is there any new business to come before the board. Is there a motion to adjourn. So moved. Second. It's been moved and seconded to adjourn. All those in favor of adjourning please signify by saying aye. Aye. Aye. Any opposed signify by saying nay. Thank you everyone and have a great rest of the day.