 And our topic is S, if it is D, hand out. No, I do not have any visual aids today, so I thought we'd just have a dialogue and... Oh, so I shouldn't be looking for something, right? No. That's why I was checking. You like that. Thank you. All right, for the record, Todd Moore, CEO of OneCare Vermont, and good to see everybody. I know that you've had my colleague Vicki Loner in a lot this session, and hopefully that's been helpful and enlightening. On this issue, I assume I was invited because I have been involved in the discussion, especially on the Senate Health and Welfare side, and testified on the topic of universal primary care. And I think I'm gonna be pretty consistent with what I told them today, and then we'll get to your questions, which is clearly OneCare believes in the relationship between a great primary care relationship with patients of all types and their best health outcomes, and lower spending across the entire continuum of care by good access to primary care and preventing and treating problems as much upstream, both from a time basis and as much upstream in the healthcare delivery system and the lowest cost settings of care. We've said for years when we got to year one of all-pair model that you are gonna see a really tangible manifestation of that as our first element of true payment reform underneath the all-pair model. And we have for this year basically move money from the acute care spending pie proactively into the primary care pie and getting more resources to primary care of all types, whether they be federally qualified health centers, independent practices, or hospital-based practices. Our most advanced model that we're piloting in three independent practice organizations is what we call our CPR pilot, and you do name it that for the other reasons that it sounds like it's CPR for independent practice. It stands for comprehensive payment reform. And what we're really trying to do is unify what is a very complex payment stream model even for primary care doctors into a more simplified, equitable, and yeah, supplemented with additional resources to make sure they can be what we need them to be. But we are blending payment streams from Medicare, Medicaid, and commercial payers, certain add-on elements that we do for other primary care physicians and even some of the blueprint support that now one care administers into a simple once-monthly capitated model across their panel of patients, regardless of whether their original covering entity was Medicare, Medicaid, or commercial. And so we've had to define what is covered in this program, what is a fair and equitable capitated model that can be adjusted for different panel mixes and demographic mixes and sickness burdens of the panel. And that's what we're moving forward with. It is one of the things that people most wanna talk about in my travels is one of our innovations. It's something that a lot of people inside and outside of Vermont have talked about for a long time of can you move to that kind of model and provide a predictable and solid revenue model for primary care to pay their doctors, pay their nurses, do good population health management, take care of their space, maybe even expand their capacity to take new patients because they got a good team-based model going and meet a wider range of needs for the patients. So that's what we're trying to do now. Certainly one of the big goals in all-pair model is to have more and more Vermonters attributed and that's a term that's from my world but it just means who's the ACO accountable for that we're actually trying to do these new models on and take accountability for affordability and high quality. And it's based on a primary care relationship. So the more primary care physicians I have in, the more payers and programs that I can contract with over time will mean increasing numbers of Vermonters will be a part of this advanced payment reform model for primary care that we've set course on. And we take that very seriously trying to spread this to more Vermonters. So a lot of ways I resonate highly with a lot of the principles and desired outcomes from universal primary care. We're trying to walk the talk a bit and jumpstart that. I do worry about the complexities of, especially if you start talking about public financing, providing benefits as a right of citizenship. Does that open up operational issues and financial issues that make it harder for me to take those next steps and expand my model? Yeah, I do worry about that. My official position is I'm sort of agnostic on whether the time's right for Vermont to do that but I can sit here and tell you that one care at least believes in the tenants and is implementing things that should be highly consistent, could be a chassis for some of the additional reforms that I know are anticipated in universal primary care such as, can we make sure that nobody's out of pocket payment to see their own primary care doc is a reason why they're not going in when they ought to. I believe in that. I believe that we can work together on that issue and a number of others that I know are important but that's what I wanted to start with today and glad to hear any other questions or dialogue that you'd like to have with me on this topic. Well your last statement answered the question I had on my mind is everything you're saying about is increased access but it's not saying anything about so one care doesn't really have any role in enabling people to use that access in terms of financial obstacles that they have, right? Nothing within your sphere controls or impacts on that. Yeah, our current set of contracts don't give us the right to set benefit models or wave co-pays or deductibles that would otherwise be a part of what people's contracts are with either Medicaid or as a Medicare or Medicare beneficiary or as a card holder for a commercial insurer. I do, my go-to line is yeah, can we be a force for good in working with those payers to figure out what would it take to waive some of them and make some progress on it so that we don't have that be a barrier to people accessing, especially primary care, yes. And I do hope to turn our attention to working on that issue. Brian, I think you, no, I thought I saw you. No, I was struggling with this chair but I didn't raise my hand. I have a question there. That's what caught my mind. Yeah, so I've been, my mental plunge. Some of you had mentioned I'd like to dig in a little more deeply on, because we've heard a couple of folks testify to the fact of an increasing complexity of the payment stream with a publicly financed universal primary care model. And so on its face, that's a pretty simple statement but I'd like to understand what that actually means. And to the effect that a universal primary care system publicly financed would affect the complexity of payment streams from a care's perspective. Would it affect it at all? Yeah, well let's- Decrease it, decrease it. Yeah, let's thank you Representative Briglin. And from an ACO perspective, we envision an hourglass when we talk about this which there's payment streams that fill in the economic sands at the top and then the ACO can work with providers to design better payment models at the bottom. And so at the top of the funnel, we get resources and accountability from Medicare, Medicaid, Blue Cross, and now we're gonna pilot a University of Vermont Medical Center's employee plan in the top of the funnel. Now each of one of those comes with the dollars associated with primary care. And that's the source of how we can then take those sands in the top, combine them together, and pay a practice across its membership in all four of those plans in a standard risk-adjusted, capitated model with a single payment. So there's the payment streams up top. So if there was a universal primary care program that might carve out from one of those payers, the primary care dollars and create a fifth revenue stream at the top toward primary care, I guess you could say that it does make our top of the funnel more complex because there's another payment stream to account for. But for us, once the sands are filled up in a rational way that again allows us to, if we're gonna take accountability for cost and quality, work with our providers to pay them in a way that's adequate, rewards that performance and simplifies the bottom part of the funnel or the hourglass, that could be okay. I'm really, when I said simplifying the payment streams, it's really the bottom part where an individual practice right now has to collect patient out of pockets. Sometimes they gotta collect the full value of the visit if somebody's within their deductible or if it's a copay model, 10 or $20 every time they see. On top of that, they send claims and wait for the money and try to count it back. For multiple payers, they get blueprint payments from Medicare, Medicaid, multiple commercial payers. They now get add-on payments, almost medical home style supplemental payments for their high-risk patients and they're attributed patients from OneCare. OneCare is providing for a quality incentive fund that the vast majority is earmarked for primary care that they can earn that bonus at the end of the year. I'm trying to simplify that for primary care across payers and really the all-pair model and OneCare is the only way Medicare will be able to participate in that program because that's part of the waiver that we have under all-pair model and through OneCare's Medicare ACO initiative where for the first time an ACO like ours can take for our in-network providers the money at the top of the hourglass in order to do multi-payer payment reform in the bottom. So we're probably the only way Medicare can even be part of something like we're talking about. And the success so far of the three practices in this blended model is it's starting to really get them excited in terms of, wow, this is great, it makes sense, it's predictable, I don't have to spend as much time sort of figuring out for the attributed lives to OneCare, am I getting these bits and pieces all together because we're trying to unify those into simpler models that bundle it up in one big payment and is designed to provide again the adequate resources for them to feel good around, we're being asked as primary care to do a lot more over time without a whole lot more money. This starts to feel right in that we can get our arms around that this is a way to test is that the right amount of resources you're paying us. In the limited time that you've been doing this so far do you have any data that shows that people are, people who haven't been going to a primary care physician now are or more people are going to primary care versus the emergency room, do you see any shifts happening yet? Well, I would say we rely on now what is almost a decade worth of not just in Vermont but sort of national evidence of the patient center medical home model actually working and elements of that are really, really highly aligned with the ACO model. We don't get attribution, they don't allow us people like Medicare and Medicaid and Blue Cross don't want us to take accountability for a patient where we don't own an established relationship with a primary care physician, right? So that recognizes how central that is to the success of the model. So I would say the evidence from the medical home programs and even just plain logic is we believe in primary care makes sense and really part of what we're trying to do as an ACO is be more proactive in primary care which is not only deliver great care to the people in your waiting room and no matter what they're there for if there's some other things that you've seen informed in the past, check up on those and make sure those are all right but try to figure out who from your panel isn't in your waiting room that maybe you might want to have in there. It's been too long since they've had an appointment or their risk factors through an encounter at the hospital where they might have had a diagnostic test indicate that something might be up. And so to a certain extent, we're pushing the medical homes in one care as part of getting the payment reform and the extra resources is to be more proactive and reach out where data would show that they ought to reach out meet those patients a little bit more where they live. Emily, do you have any data on, because they go to primary care, I mean that's a focus, that they're spending less money on more specialized businesses like cardiology, the diabetes doctor, are you finding that primary care is keeping them kind of in control more soon that they're not spending or is it too early? AMO? Yeah, so. What about other studies? Yeah, so I don't know, we have not done and I have not done anything in terms of is there a correlation for somebody who has the exact same illness burden as the exact same age and sex, if they have more primary care visits, is there total cost of care less? We live in a world where their total cost of care is best predicted by how old they are and what their disease burden and problem list, medical problem list is and we're trying to even get further into what do we know about any barriers to them engaging in their own health and certain mixes of comorbidities to try to fight through that, but I would have a strong hypothesis that those who are engaged in their own healthcare enough to call their primary care doctor or go in for regular visits and if something isn't right to go in and see get a primary care dialogue going, I gotta think that they do have lower utilization of better outcomes. But that's an assumption not based on any. I just personally have not seen anything that says if you see your primary care doc five or more times if you're of this disease burden that somebody who sees their primary care doc two or fewer times has different outcomes. I just haven't seen that. I think I was talking more about specialized visits of senior cardiologists. If you do see your primary care, do they keep it more under control that you're not spending money also visiting your cardiologist, people with multiple kind of diseases reaching out to specialists? Do you see any money saving going out to specialists because of primary care, I think that's the question. Well, yeah, I think certainly so. The more people will discuss with their primary care physician, the entirety of what they think their disease burden is before they would call even if they have the benefits to do it, call and get an appointment with a specialist. Yeah, that actually is a very good thing and certainly we use the term medical neighborhood when we want there to be a specialist involved in the care. So we look at it both ways. One is, yeah, we think primary care should be the quarterback of the team for the wide range of problem lists and primary care have built capabilities over the last 10 years to credibly manage the care and disease burdens of increasing number and increasing complexity of medical problems. Yes, but we wanna do the same thing I mentioned in terms of people who don't take the initiative to call the primary care physician when they ought to. If there's an indication that somebody's chronic illness isn't being well managed, we want the primary care doc to reach out to a specialist and say, hey, we need to work together on this patient situation. What do you think? Let's let me take you through it and they agree that that patient ought to have a specialist consult as part of their care. We wanna encourage that sometimes when it's not happening. So it could go either way. Right. So part of our discussion has been looking at the bill that came to this committee from the Senate and the version of the bill that left Senate held them welfare. And I'm curious from your perspective, what are the pros and cons of each of those bills? I would say that if the state is gonna pursue universal primary care that requires a how would we define what primary care services are? How would we determine the right level and type of payment to make to them? How do we actually operationalize that payment? That piece in my mind has to align with the ACO and all payer model approach that those can't go into urgent directions. Now I will say that the all payer model is the deal that the state of Vermont and the providers agreed to pursue as our primary reform. And I wouldn't wanna do anything that slowed down our progress and success in that arena to try to keep those in alignment. So that's one thing I liked about the Senate Health and Welfare bill is it baked in some of that alignment by making ACO sort of a named piece of the leading stakeholders to help anticipate how we would design that. Now I think we all realize that it's a big deal to set course for something that would contemplate public financing for a health benefit and sort of tests in new ways. Can that alignment happen? And would this cause a distraction or a derailing of all payer model? Count me in and somebody who would worry about that. And so I think that's the strength of something more close to a study bill to just sort of assess what does that minefield even look like so that we don't step on anything by trying to push it harder. Well just that, you said the strength of the first bill was that the ACOs were involved. And it looks like in the second bill it doesn't specifically name ACOs unless I'm missing it. But it does say that the Vermont Air Board would convene interested stakeholders. So would the ACO be an interested stakeholder? Absolutely. So in this discussion about S53, I think it's been emphasized that one of the benefits is it's universal and everybody's involved. In all payer and the reform that we're pursuing right now, I think it's important that it is rolled out quickly. So do you think you're on track for meeting the scale requirements of your model? And are you optimistic about that? I think that we just started the model. I mean we're not even four months into it and sort of one of the dialogues I would love to have with the legislature over time is how can we work together to drive the scale targets and have the ACO model be one that you support and are proud of and want to help encourage. So I think we're gonna need the dialogue and some help. You guys were gonna need to be a part of that and envision success and support for the model. But I think that's a team sport driving the scale targets. I have to say I've been personally very disappointed at the progress so far, the limited scope and size and we'll have to see, but Betsy and then Brad. So I'm just struggling to see pieces of this and just don't get, I'm sure that you might feel the same way. I think I would have the pyramid more than our last because I see the money funneling up from primary care not down to primary care. It needs to be started there on the base because that's where the foundation of our health care is going to be established. And I don't see why even having Luke Ross-Bruxell and the various payers be there and we have public funding to that as well. Add it to that so we increase what happens at that primary care level of payment. I think that could drive the cost of everything down. Can you imagine how that would work at all? I mean, just take out of your position. I guess I'm asking you for- Yeah, no, and I understand- So initiate yourself from one care. Yeah, no, I understand the spirit of what you mean, the pyramid. But at the end of the day, somehow a primary care physician being responsible for a panel of patients gets money into their practice to again, afford the expenses of their practice, right? And so that's part of the trick of this is operationalizing it, is where does that money come from? Who's the agent that then transfers it and on what basis is that transfer made? What's the right amount for an individual primary care practice across its panel for its attributed lives within its panel or for an individual patient? Those are all problems that we would be working on under a universal primary care model. And it's one of the problems that we work on every day in terms of trying to do it under an attributed model and the ACO model that gives us finally some flexibility. And so if traditional fee for service, it's the payer who determines how much to pay a primary care practice for each individual kernel visit. The ACO model that we're implementing under all payer model for the first time allows us to bundle those from the payer as long as the providers are okay and signed up for this, bundle those from the payer and give it to them in a way that they will from a bottom up perspective say, that's a lot better, Todd. We like that a lot better than the fee for service system. So I think we're sort of on the same page. And it isn't so much that we go in a back room and design this and say on January one, hey, here's how you're getting paid, hope you like it. I mean, we have this dialogue with our primary care docs to say, how do we be a force for good and how much more do you really need if this is what we're expecting you to do to be accessible and proactive and deliver high quality care and worry about what happens to your patients when they do need a specialist or end up in the hospital. So hearing you talk about this issue from the perspective of the ACOs, it sounds like there is some alignment between the concept of universal primary care and what you're doing, because you were just talking about the idea the way that you're paying primary care physicians, you're trying to design it in a way so that they can take on like sort of a case load or a panel and then be fully funded in a way that they can run their practice smoothly and I think that would be the hope of universal primary care, but there are still some gaps between, there's some gaps that exists like in terms of accessibility like you mentioned earlier in terms of co-pays or deductibles being involved for some people as well as not wall insurance companies are participating in PACO, right? So what I'm wondering is how if one of these bills or something different be the best path to move from where you're at to a more universal system down the road. If it's not one, in other words, would one of these bills be the best path or is it something that we're not seeing before? So if so, what do you think that would look like if the people of Vermont in this body decided we want a universal system, but we wanna build it on what you're doing? You know, in other words, how do we get from here to there? So the answer is if we do decide we're gonna pursue this as a state, I think it's gotta be aligned and if I do get to 70% of Vermont on the scale targets, the primary care payment model for that 70%, really I don't match the other 30% if we go universal, right? So that I think is a first principle. I guess it really boils down to almost a first do no harm. Are we risking slowing down really tangible good progress that we made this year expect to make next year by bringing in this whole design element all together, right? And is there enough change management and design bandwidth to do more than all payer model and what we're trying to do in building the scale targets of the 70%? I think that's a legitimate discussion in terms of really do we need to put our eggs in the basket of what we've signed up for as a state and use that to the greatest degree possible and work together to get more patients in there and Senate Health and Welfare asked me look at this ACO based model with your big network. I mean, if there were still uninsured Vermonters that we just wanna figure out how to get them access to primary care even if we can't fund hospital insurance form, can your network work on that? I think the network would be interested in working on that. I know you're gonna talk to Georgia Maharis on behalf of FQHCs who that's really their role in every healthcare system where they exist is you can walk up to the front door of any FQHC today and you're gonna get seen and be able to establish your relationship. We have some good building blocks here in Vermont to really make some progress on this working together. Raising the specter of public financing and the benefit of the right of citizenship and all the political ballast that's gonna bring in and sort of the stakeholders are gonna wanna be in the room and you're right, I'm gonna wanna be in there, have people in there really to participate and it's gonna take me off from how can I make more progress next year? I'm not gonna lie, I really do worry about that and I'd prefer to take one more step and maybe live to talk about this another day on how we can maybe go beyond 70% in the scale targets if we can get some momentum. So, although this is the first year of the empire, last year we had the pilot year of the empire and if we were your board of trustees, what would you say are your successes from this? Well, it's almost a full year from then, it's a little more than a full year from when you started the SQ at this point. What would you say are the successes that you're seeing? Yeah, that the full continuum of care and different types of primary care and different types of hospitals working together is a really good thing and they can collaborate in ways to build a system around the needs of a patient and that we can set a target that represents value to a payer, both quality and affordability and predictability and live within our means as a healthcare delivery system. So, I understand that the capitation and the state where you need to be, but the quality aspects, I mean, in seeing that you had a slope of quality that you had to reach for and I understand that no, as a nurse, you're not gonna reach those in 60 days or even a half a year. But over this year, with the same capitated large you've had this last year, have you seen changes in that quality of what their own situation is? Yeah, I mean, we use the same quality measures by and large as we use during the shared savings period where it was what we call upside only sharing. If we save money, we get to keep some of it, but not as much of it if our quality isn't good. And if we spent too much money, we didn't get anything and the quality really didn't matter. But we've been doing these quality measures for five years. So even under the week incentives, for five years in all three programs, we increased our quality scores year to year every single time. I have not seen the results for last year because we're still in the period of collecting retrospectively what those quality measures are. But one thing the ACO model has proven to be even with weak financial incentives is really, really good at measuring improving quality that the providers really rally around that. And I expect that to continue. And do we get a new set of quality indicator data? At any time, I mean, there are very specific ones that you had to work on. Yeah, the Greenmont Care Board has published the quality outcomes for all programs on an annual basis. It's usually about two thirds of the way through the year because that's by the time you get the patient satisfaction score is all tally for the previous year. And so there should be one out there from I'm gonna guess maybe October of last year. For 2016, there'll be one September, October this year. For 2017. And certainly, any of my clinical team, we glad to come in and talk to you about the multi-year quality improvement track record and probably give you a preview of what we're seeing from what measures we are able to measure for last year already. I'm sure they'd be more than happy to come in and talk to you about that. I'm happy you're staying within your money, but it's really what's happening on the patient side that I'm most interested in. Great point. Anyone else? Well, thank you very much. Yeah, I'm glad to be here. Good to see everybody. Next, to tell us about... No, I'm sorry. I'm sorry, yes. Am I really? Yeah, from you. Same set of questions I have. Yeah. I'm sorry. I apologize, I was looking at the wrong sheet. Okay. We have George Meharis up next. Oh, and my apologies, I'm getting over a cold, so I have a little more in terms of notes and reading than usual, because I'm still a little floggy from the court of medicine. Please. For the record, I'm George Meharis from Bi-State Primary Care Association, and as Todd indicated, we represent Vermont's federally-qualified health centers and also Planned Parenthood and the free clinics. And so I just wanted to make a few points on this bill, which I said the same in Senate Health and Welfare, so apologies to the audience for hearing it for the sixth time. They don't matter. They don't matter. So as Todd mentioned, actually, one of the most important things we do across our federally-qualified health centers and actually the free clinics and Planned Parenthood as well, is as part of our primary care safety net, we serve over half of Vermont's uninsured. So in terms of folks getting access to services, over 12,000 Vermonters who are uninsured are going to the same patient-centered medical home that I could go to or you could go to with your insurance coverage. On top of that, we have about 1,500 folks who are uninsured who go to Planned Parenthood and over 1,000 who go to the free clinics. So we're covering and taking care of a lot of those individuals who I think are part of the focus of this legislation. Just to remind you that RFQHCs offer a sliding fee scale, so it's based on an individual's ability to pay. So depending on where you fall on the income chart, even though, say, it's a $20 office visit co-pay according to your card, you may actually pay less than that. And additionally, if you don't have any money, you still get treated and taken care of in your appointment. So of course, we support increased investment in primary care. I mean, it's in the organizational name. It's what we do day to day. And we agree that there's a high return on investment for primary care services. We do have some concerns around the universal primary care system, and I think some of my colleagues have referenced those because the devil's in the details as you all well know of any healthcare program. Our first area of concern is around administrative burden. So you may have heard from me or literally any doctor this session, just talking about the sheer burden of administrative tasks that in particular primary care clinicians are kind of suffering under. We wanna make sure that that doesn't get increased. And frankly, if there's another payer somewhere in the mix, that means there's likely more paperwork following that payer in the mix. Additionally, there's, this would impact our recruitment and retention ability. So what's to say that if the administrative burden in Vermont is already high and a deterrent for recruitment and retention, if you increase that, what kind of unintended consequence would that have? So to us, it's unclear what the value would be to incentivize clinicians to come if we're having a kind of commensurate increase in the administrative burden. The third point, and this was actually made by Todd earlier, our members are experiencing what they call reform fatigue. They've been working for a long time. The blueprint for health was what, 2007? That's over a decade of kind of successive reforms in different efforts. So currently, they're all in on improved equality and lowering cost trends. But there's a worry that adding another layer of complexity to this already fatigued workforce, not to mention the administrative staff who are busy volunteering their time to participate could again result in some unintended consequences. And then finally, the concerns are on behalf of our patients. And I'll admit that this is a little bit of what I'm George's favorite things. I'm not sure all of you are aware before I came to Vermont, when I worked in Boston, I was a consumer advocate for five years. So the patient experiences here did my heart and the organization I worked for was engaged in a lot of outreach and education for patients and helped line for folks who encountered problems. So if you add a new coverage benefit, it'll result in confusion just because it will result in confusion. Patients won't really understand what's covered so we need to have significant outreach and education. Our members currently spend a lot of time assisting patients in navigating the current system. They would have to spend more time. And so one kind of scenario that I was thinking through was the current UPC benefit structure, and this is the one described in the 2016 report, doesn't cover medications or lab work. So Georgia, who's a diabetic, walks in with my new personal primary care card. My visit's covered because that's one of the codes that's covered, but my lab test isn't covered and my prescriptions aren't covered. Well, we hope that I still have my major medical plan, it didn't drop it in my confusion. But what if I did? Or what if I went in and just had a universal primary care, because I'm like 28 and super healthy, I'm like, yeah, I don't need that. And then I do some, care my ACLs, this is what happens, right? So there's just a concern around confusion, significant medical debt, and just so making sure that whatever happens, we really have to have a significant amount of outreach and education just so we don't end up with people in the worst place or again, those consequences. I think the final suggestion I would offer, and this relates to some of the concerns that I heard in earlier testimony about affordability, and I'm thinking back to that big hearing down in the house chamber that I believe you all were in attendance for. One of the issues raised was that individuals cannot afford the co-payment or the deductible for that primary care visit. So it was a real deterrent for folks even wanting to walk in the door regardless of a sliding fee scale or whatever. And so then individuals would wait until the situation was dire, then they would face significant health impacts, financial impacts, not the outcome we want. So I would offer that it's actually possible that we have something slightly simpler and faster which is just having first dollar coverage for all primary care services. So right now the Affordable Care Act has in place that there's first dollar coverage for preventive services. We as a state can make a decision to expand that to more than just preventive services. And again, a company without reaching education that could perhaps mitigate that deterrent factor on that doesn't require years of planning and complex operations. So I would just offer that as an additional way to deal with that particular challenge. And I know that some states are similarly finding other solutions to increase the primary care investment as a percent of premium and things like that just to try and have faster solutions frankly and other solutions that address the concerns that they're facing. So that I will pause and answer any questions you may have. I'm really curious about the last thing you were talking about because I was writing my question up and I'm gonna read what I wrote. Sure. So I was, you were sort of making the argument it's gonna make the system more confusing but it also acknowledging that it's already incredibly confusing system. And you know, ACO healthcare reform, it addresses the situation for payers, not the patients. And I was gonna ask you how do you propose we address the affordability and accessibility issues for patients to get primary care. And then you said this thing. So I'm curious. Can you give me a question representative? Yeah, so but I mean, I think I would like to hear more details about what exactly you mean because if this bill before us is not the best thing if we can do anything in this session to take a step in the right direction, I would like to do that. And so I'm curious if you could explain like what that means, first dollar coverage. I don't totally understand that, to be honest. Sure, I'm looking to see if it, those look like the insurers are in the room so I can talk more freely. You're on tape, don't forget. They know I have this idea. So the idea would be similar to how right now if I go into my annual wellness checkup to my primary care commission, I do not have to pay co-pay despite the fact that my card says $20 office visit every time I go into a physician's office. That's because the Affordable Care Act says thou shalt insurance companies not charge there. We could similarly in Vermont say all right for Medicaid and commercial. We can't totally control Medicare but maybe Todd could figure out a way to help work on the Medicare side. To say hey for commercial carriers that are licensed in Vermont, which goes through DFR, thou shalt not charge. It would impact premiums to some extent. There'd be some actuarial stuff that I won't pretend I don't know how to do what those smart people would do. But it could be a way to make it so those services are paid for before the deductible gets triggered and an individual doesn't have a $20 unpaid bill from a primary care visit that was just not affordable to them at one. So can I just expand this more, put it to like for what would maybe a real situation and then for people who don't aren't like steep in healthcare policy it might illustrate if I get a tick bite not that that happened in the last year or anything. And I go to the doctor now under my, if I go for my physical in two months or whatever it is I don't have to pay anything for the physical. I did get a bill for the blood work. So you mentioned a lot of stuff. I did get a bill for that but the physical itself didn't cost anything. But they do charge for the physical if the preventive physical they actually find something then they charge you for the tick bite. Oh, so I'm lucky that they didn't. Right. Okay, so thank you for illustrating that. So I'm lucky that they didn't find anything. But they did good work in terms of, you know, having a nutritionist talk to me and things like that, right? So trying to do some of this population health work that's great. But then when if a tick bite happened to happen a few months later and you went in and then you get like a $90 bill and all they did is kind of poke at it and say, take this antibiotic. You know, there's some people who may not go in for that tick bite if they find out that it's gonna cost them $90 and then they get Lyme's disease and they get really, really sick and then it costs them thousands of dollars or our system and the taxpayers thousands of dollars. So it sounds like what you're saying is we have the power, or we may have the power to tell insurance companies that they have to cover those basic primary care visits besides the physical for all diagnoses but it might have a financial impact. It might make premiums go up. Is that what you were saying? Correct. Okay. It would be, and I see your lawyer's not in the room but I would liken it to a similar any mandate that you implement in the private insurance market. Did you say that other states were looking at this? So other states are looking at this. Is it successful and how many states? So I don't believe any other state is doing this specific thing although I don't take credit for coming up with the idea but what a lot of other states are doing and notably Rhode Island and Oregon have been doing it longer so they have a little bit more data around their success is that they are just in general increasing the amount, the percent of total healthcare expenditures that are spent on primary care. So rather than the 7, 8% that we spend annually in Vermont, Rhode Island is I think at 13%, not as much as some other countries but definitely better than we're doing here and the results are that it does show some of those benefits you were asking about earlier in terms of reduced utilization of certain specialty services or avoiding full-blown Lyme disease or Georgia going to the hospital with pneumonia or whatever it is based on a cold so. I think we had testimony last week and I'll try to find out who it was that said we put $14 million more in primary care in Vermont this year and I think it was in reference to those things. And is that something such as if you're talking about spending more money? It depends on how it's spent I guess. I think that relates to the testimony we got from Rhode Island and then noting that we actually were already doing a lot of the things that Rhode Island said they were doing. In terms of that end of supporting primary care which is not the same as the direct access end. Exactly, and my understanding is that there's different layers of investments so one example is that the ACO could independently do some additional investment. Medicaid I know had some increased primary care investment this year is in the governor's proposed. In Rhode Island it was through their commercial payers. The doctor sure as man fine I went yesterday. Yeah. No I was really, his budget actually cut payments to primary care but. One bucket of payments but then increased in another place so it depends on who you are and where you sit. We ended up losing. But I think it's, there's many ways to get at that increased investment I guess is the point. The particular one I was describing hopefully we get more at the patient level which I again I heard was one of the areas of concern that was raised over and over so I figured it was really good. Lord. Sure this question can be answered so tell me that if it's, if you can't. You know the FQHC model of my mind is exactly what we're trying to do. So for those people who are uninsured and are not going to an FQHC, do you know why? Is there a study done or do you have thoughts as to why we're not capturing everyone? So I have a little bit of a thought because in particular actually there are a lot of individuals in the Northeast Kingdom who are not accessing services. Just it's a very, compared to other parts of the state. And one of the bits of analysis that that health center actually did is there's desire by the individuals there to not take a handout. And it's a very strong, well-seated one. And so there's an effort, frankly, a newfound effort to say okay we'll get into the schools. So teaching, getting at someone when they're younger before some of those. So they can see that it's not necessarily a handout, that it's really part of the day-to-day life. It's similar I think to some parts of the state where historically getting dental services was not what you did. And so we're continuing to fight on that front as well. So I think that there's a complexity for a certain subset of the population where it's just, and it's not something that they want to pursue. I do also believe, and you have to talk to Blue Cross about this, but I believe that they've done some analysis around some of their beneficiaries who are not accessing services and there's a chunk of younger, I wanna say male, but again please check with them, where it's just, it doesn't cross their collective paths. And I would note that as someone who has a spouse who's not quite as young a male as he once was still thinks he is, and so he also doesn't like to access medical services, so there could be something to that. And there's no part of the state that you see doesn't cover the service. Correct. So I hear what you have to say, but I think that a piece of that is that when you come to people who don't access the care, sometimes it's that because of the dearth of primary care providers that it's out eight months before you can even get an appointment and they don't have the clue what they're gonna be doing in eight months so they don't make the appointment, then eight months comes and they still don't have an appointment and so it kind of like falls back and back. So it's a piece of the run, no primary care providers to be gotten to see. And there's also, they tried the clinics for the coalition for the unassured that came and talked with us. They did have an uninsured clinic up there, but it failed, they didn't make it work. And they have a huge representation that they take care of in the Middlebury area and south of there. Can't remember where I was down there, maybe. I'm not sure, but I know in Middlebury. And it seems to me that what they were talking about in Rhode Island, what they were just starting to do were the medical home model that we did years ago. And so we're ahead of them on that piece. But I think they are ahead of us in what we funnel to primary care. And that I think would attract doctors here if we increase the amount. And that's kind of the question I had through you, Mr. Moore, was about if we funnel more money towards the primary care because coming down to the primary care kind of goes through the hospital entity. It's how I visualize it, coming down because instead of going up from the primary care into higher and higher treatment based on what their needs are, you're coming down from there. And that's why I'm... That's one of the 14 million. Yeah, that's exactly it. But it's just trying to make sure we are funding more to that primary care level than we are down because it's very clear that we don't have enough at that level. And I'm not sure how we go about that. I'd say we're doing it right now. That's what the 14 million is. And you're putting all 14 million into the primary care. Yeah. That's just the brand. Okay. Thank you. Any other questions for Jordan? Thank you. Thank you for that idea. Yeah. So. I did it. We did it. You're not there to put that in. Yes, right. So we don't have anything on our agenda until four or we're finished up for this piece. But just a quick update, because I think I'm not sure if everybody was here when Bill on Friday afternoon referenced what was going on with our mental health bill. So we pulled it off the floor back to committee because originally what we thought might happen back over in the Senate, it turns out it was maybe gelled enough for us to look at adding some language explaining the intention of what we hope is gonna happen with some of the new ideas with psychiatric inpatient and secure residential. And brand new actually, I haven't heard the details yet, but brand who also the whole interim, what do we do in the interim before new facilities and before more community things help fill in. I guess the Senate was looking pretty favorably towards the forensic unit in Swanton that we had kind of panned. And AHS was working very hard on kind of the direction that we had supported. And it looks like they may have a proposal that may work out for interim, working with the Brattle River Retreat for an interim facility. So at four o'clock, Algo Bay is gonna be in to present to us about that. And we have some language from Katie to look at as far as what changes that would mean in terms of language in our bill and some thoughts on that. Because of where our bill was, it means some, there's always these fun little jurisdictional things. The Senate was hearing about this, the Senate Institutions Committee, which has the Capitol Bill right now, was hearing about this earlier this afternoon. So they were hearing the information about the Brattle River Retreat alternative to the forensic facility proposal. And they're testifying tomorrow in house institutions. But I spoke with the Chair of House Institutions to keep all of the peace on those things. And she's fine with us hearing about it first and her hearing about it, their committee hearing about it tomorrow. So that's what we're doing it for. So, thank you. Let's get up, take the overwhelms and see everybody done.