 Good morning. This is a joint meeting with Senate Health and Welfare, House Health Care, and House Human Services. It is January 26th, and we're looking forward today to hearing from the Green Mountain Care Board an update on some of the Act 167 work that's been going on. So before we begin and have our witnesses introduce themselves, I'm gonna introduce myself. Each chair of each committee will introduce him or herself, and then we will begin. And just as upfront, we have a lot of people who would like to ask questions. So if you could each indicate to your chair that you'd like to ask a question, and then I'm gonna leave it to folks at the Green Mountain Care Board to decide if they wanna be interrupted during their presentation or not. So just, but we'll do it through the chairs. And I can't monitor that, but each of the chairs can do that. So we'll see how that works. So as I said, I'm Senator Ginny Lyons. I represent Chittenden Southeast, and I chair the Health and Welfare Committee in the Senate. So let's go to House Health Care. I am Dr. McFaughan. I'm the vice chair of the House Health Care Committee, and I represent Barrie Town and part of Williamstown. Good morning. My name is Teresa Wood. I'm from Waterbury. I also represent Bolton Beale Score in Huntington, and I'm the chair of the House Human Services Committee, and our full committee welcomes you. Thank you. So welcome everyone, and welcome folks from the Green Mountain Care Board. I will turn it over to you to introduce yourselves for the record, and then let us know how you would like us to interrupt or not interrupt as you go forward. Good morning, and thank you so much for having us. I'm Sarah Kinsler, Director of Health Systems Policy at the Green Mountain Care Board. I've been with the board for about five and a half years and with the state for eight. I came here originally in 2014 to work on Vermont State Innovation Models Grant. And before that, I spent a few years working at the National Academy for State Health Policy, so working with states all over the country to help them implement best practices in health policy. I'll hand it over to Sarah. Good morning, Sarah Lindberg. I've been with the Green Mountain Care Board for a few years now. Until this past June, I had led the data team, but now I'm leading the finance team. I've been with state government even longer, started back in 2010 at the time, it was the Department of Education, but I'm a statistician by training and looking forward to talking with you today. Welcome, Interruptions. Don't be afraid to interrupt me ever. Perfect. We do have kind of breaks built into our presentation and opportunities for questions after we discussed the section one of Act 167 work and then again after we discussed the section two work. So if that's convenient for the chairs, that's also an option. Sounds good. Thank you. And thanks to Julia for getting our slides off and I'll shuffle things on my screen on our end and get us going. All right, thank you so much. So I know that some of you have met our chair, Owen Foster, and he will be in Senate Health and Welfare tomorrow morning, but for those who haven't had it yet, we wanted to at least start with a very high level overview of the Green Mountain Care Board structure. So in 2011, the legislature established the Green Mountain Care Board as an independent transparent board with an important charge to improve the health of our monitors in the healthcare system that serves them. The board has five members that are appointed by the governor to staggered six year terms and relies on a dedicated team of 27 staff members with expertise in various healthcare disciplines, including finance, accountable care organizations, certificate of need, health policy, data and analytics. And so much more, I don't wanna miss any of the expertise of my colleagues who are so amazing. Related to today, I'm just gonna touch on a couple of our core duties, specifically the regulation of hospital budgets and supporting specifically the reporting and operations and a few regulatory functions related to our current all-pair model agreement with the federal government. So this is a slide that Chair Foster shared with Health Healthcare last week, and I borrowed it today to briefly touch on the board's public processes. GMCB has a very transparent process, including being subject to open meeting law, which means that for most areas of the board's work, they can only hold hearings and deliberate in public. This means that the public really gets a front row seat to the board's work, and last year we had 52 public meetings. Furthermore, public comment is really important to the board's work and there are many ways for the public to engage with us, both at public meetings through written public comment. We also have extensive stakeholder engagement through roundtable discussions that the board occasionally hosts on timely topics, as well as through our advisory groups, which convene regularly and allow board members to interface directly with providers, with consumers, with other key stakeholders. Finally, I do wanna call out that the healthcare advocate is really central to our work and a critical collaborator in support for us. They have a formal role in many of our processes, including hospital budget review, and we work with them in nearly every area of our work. So Sarah and I were asked to come in to talk about the board update on Act 167, sections one and two, which I should have mentioned earlier. We just submitted a report on this topic. So some of these slides will look very familiar to you if you have seen that report and it's on the legislature's website. Some of you are really familiar with the history that kind of led to the development of Act 167, but since I know many of you are likely still getting oriented to this work, we wanted to provide a little of the background on how we got here. So those who are members of House Healthcare, Senate Health and Welfare last year took a ton of testimony on this. And I know Representative Donahue on the Human Services Committee was also very familiar with this work from her time on House Healthcare. This is a really big bill. So big picture, it's the board's work to regulate hospitals that has brought these issues to the forefront for us. Harkening back a couple of years, in 2019, the legislature asked the board to convene a Rural Health Services Task Force the purpose of and I'm all quote now to evaluate the current state of rural healthcare in Vermont and identify ways to sustain the system and ensure that it provides access to affordable, high quality healthcare services. There were 14 members to the Rural Health Services Task Force designated in statute and the group met through the second half of 2019 and brought together a lot of people to think really hard about the future of Vermont's rural healthcare system and how to ensure that all Vermonters can access high quality affordable healthcare. So the kind of cover of that report is right here and there's a link to the full report on the next slide. That same year, the board required a subset of hospitals to develop sustainability plans due to persistently low and declining margins and the news that Springfield Hospital would enter bankruptcy which I know was kind of a shock to the system in the state. In 2020, we expanded that requirement for hospitals to develop sustainability plans due to COVID-19 and start the public health emergency. And that same year, in part building on the Rural Health Services Task Force work, the Legislature passed Act 159 which resulted in a significant report on hospital sustainability and hospital sustainability planning which also linked on the next slide. That report was kind of developed throughout 2021 and submitted in early 2022 and that kind of brought us to last legislative session when Act 167 provided GMC with 4.1 million in dedicated funding for the activities that we'll discuss today and in pursuit of hospital sustainability and health system sustainability. There are really long running themes here that go from all the way from the Rural Health Services Task Force through the board's requirement that hospitals produce sustainability plans to Act 159 and Act 167. And I think that this quote from GMCB member Jessica Holmes the testimony that she provided to two of your committees last year really encapsulates that. So I'm actually going to read it to you now. Apologies in advance, Tully. We'll look at the other screen where it's posted a little bit bigger. So what Jessica said at that time is we are not on a sustainable path and if we don't act now with intentional payment and delivery redesign market forces will take over. Some hospitals will go bankrupt, close or come to the state for emergency relief as Springfield did asking for and receiving millions of state dollars to keep its doors open. And it will be those hospitals serving our most vulnerable patients that will fall first. Other hospitals will divest the central services and it will likely be the least profitable services like primary care and mental health that will be shed first. It is already happening. We need to act swiftly and courageously to ensure a sustainable high quality healthcare system. It may sound like a large investment but think of the cost of doing nothing. So Act 167 sections one and two is really the culmination of all of this work. And we think it sets us on the path to work closely with the legislature to make transformational change. So this slide, this next slide is from the report itself and provides a bit more of kind of the full information and timeline of the work that I described. So we just wanted to include that again so that you have those links and that timeline at your fingertips. So Act 167, diving into it now, this visual shows how we kind of mentally break up the work that goes into TAC 167. So in sections, and specifically in sections one and two, I do wanna say there's a whole bunch more to Act 167 that we're not gonna touch on today but specifically to sections one and two. So the first kind of bucket or work stream is a subsequent all-pair model agreement that is led by AHS in collaboration with GMCB. The second is developing value-based payment models specifically hospital global budget development as we're focused right now. GMCB leads on that with a collaboration from AHS. The third is evolving GMCB regulatory processes and we're focused right now on our hospital budget review process which Sarah will talk about much more deeply and that's the GMCB's work. And then finally, community engagement to support hospital transformation. That's GMCB led with important collaboration from the agency of human services and that's the section two work. So first off, we'll touch on the all-pair model. The current all-pair model agreement represents really close collaboration between GMCB and AHS. GMCB takes point on data and operations related tasks like reporting results to our federal partners while AHS is the policy and strategic lead particularly for the development and negotiation of a potential future federal state model with our partners at the Center for Medicare and Medicaid Innovation or CMMI. This past summer and fall AHS convened a healthcare reform work group of key stakeholders to discuss a potential subsequent federal state model as well as other issues. And the board was a participant on some of those topics including those related to the APM and actively collaborated on those topics in meeting planning, agenda and materials development and meeting discussions. So there really was close collaboration there at every level. In December, an extension to the APM agreement was signed by Governor Scott, AHS Secretary Samuelson and Chair Foster. This extends the agreement for potentially two years, a one-year extension for 2023 plus another year at the state's option which would provide a bridge to a subsequent federal state model if Vermont chose to participate in one. And I've also linked to the testimony that House of Representatives and a health and welfare received from AHS over the last couple of weeks which provides more information on that. So next we will move on to the payment model development work. And the statutory languages included here and you'll see that while there's some kind of openness in the language, global payments are one of the models that we're required to focus on. And so that's where we're starting. I made the mistake in my own slides of really using global payments and global budgets interchangeably. So hopefully folks will roll with me there. But what is a global budget? So a global budget provides a fixed amount of funding for a fixed period of time, usually a year for a specified population rather than fixed rates for individual services or cases. So in developing this payment model or any value-based payment models under Act 167, we are required to, and I'll paraphrase here, develop payment models that will move away from fee-for-service that will provide hospitals with sufficient predictable, sustainable and aligned funding across payers that will consider the costs and operating expenses of healthcare providers and not be based solely on historical charges that consider Vermont's morality and that identify the appropriate role of global budgets for Vermont hospitals. This is another area of really close collaboration with AHS. And so we've got a call-out box here on that AHS healthcare reform work group which I mentioned on the prior slides, which included a global budget subgroup to help inform CMMI thinking on this issue. And that stayed really at the high level regarding kind of flexibilities. But starting this past Tuesday, we are continuing this work together by digging into the more technical details. So GMCB and AHS will be co-chairing a technical advisory group on this topic. And it's very focused on the details of that methodology. I've sent out a line. We have a question from the healthcare committee. So I'm gonna ask if you'd like to, do you wanna, is it something of clarification at this point? So go ahead and ask Green Mountain Care Board folks if they would like to respond to it at this point or wait till the end of the first section. Do you wanna be interrupted in your presentation for a question, is it? I am happy to answer a clarifying question or maybe that we get to an answer in another slide or two. So we're happy to do that. Go ahead and ask the clarifier, go ahead and ask the question. If it starts to move out into the weeds then we'll come back to it later. Thank you, Senator Lyonson. Thank you, Sarah. Thank you, Chair. Vice Chair. This is Leslie Goldman. I just wanted to ask this question before you went on your detour and you may decide to take it up later but I'm just gonna put it out there. Since this group is working specifically on hospital global budgets, what I'm wondering is this language and does this work allow us to go beyond hospitals for global payments, including primary care particularly and issues around population health? So that's what I'm wondering is does this language and process allow us to look beyond hospital global budgets to places like primary care? Thank you so much, Representative Goldman. That's a great question. When Inabak has testified before you last week, she talked a little bit about how the agency is pursuing a portfolio approach for its payment reforms, I believe. And because of the board's regulatory focus and because it's specifically mentioned in the statute, we are starting with hospital global budgets. Honestly, this has enough complexity on its own to keep us really busy. We know that we'll need to understand connections across the system, however, I think the potential to expand a payment model in future years or develop complimentary payment models is not at all off the table, but we need to start with a more focused approach. If I could just delve into the weeds a tiny bit for a moment that where this will vary is where potentially where hospitals own other types of services or where kind of professional services could be brought in. In a minute, we're gonna get more deeply into the topics that the work group will discuss, and I think that will kind of show you how at least we'll be engaging stakeholders in those conversations and kind of trying to understand the various complexities, because there are so many. Thank you, much appreciated. So, I guess getting back to our detour, we're gonna take a couple of little detours in this presentation where we think it would be kind of helpful to contextualize what we're doing and to kind of remind folks of the conversations that we had last year. So during the 2022 legislative session, lawmakers made really clear to us that sequencing the stakeholder engagement to ensure coordination and minimize burden was a really critical consideration, especially for healthcare provider organizations who are so maxed out by the work of the past few years. The board and AHS have collaborated really closely to that end to try to make sure that our stakeholder engagement processes are not overlapping more than necessary and that we're being really mindful of the burden that we're placing on stakeholders when we ask them to engage with us to help us kind of design this future work. So I have a little mini timeline right here, but on the next slide, I'll show you our slightly more overwhelming timeline. We really wanna give you a glimpse of how we're coordinating these works for you. We're not laughing at the content, but it gives us quite a shock to see it. We can't, but we have it on our iPad, so that's good luck. We feel your pain and this is not here necessarily to ask you to dig into the details, but we wanted to help you understand, this is kind of the, to make it even a little bit more scary, this is the summary visual. So if it looks like a lot, it's because it is a lot. This is a lot of work and we are, we're working really hard to make sure that we sequence it in a way, a way that is really thoughtful for our stakeholders that ensures that the work can be well coordinated but not having everything come at the same time. So what I'm really showing you here. Sarah, did you submit your slide deck to Alex to post on our committee web pages? Yes. Okay, good. So we'll be able to see another all in one. Yeah, okay, that's great. It's not actually up there yet. It's not up there. Alex, we'll get it. I think Lori, Alex, and Julie will have to each, put it on each committee web page. Okay, thank you. We got it in fairly late yesterday afternoon. So what I'm really showing you here is how we engage the stakeholder work is in each bucket, but also how we've tried to kind of spread that out across the time period that we anticipate this work will take. Those yellow boxes are kind of stakeholder engagement buckets and we really have done our best to sequence and stagger them to avoid duplication and minimize burden while also recognizing that this isn't work that the state can do in isolation and that we really need not just healthcare providers but the kind of the full range of stakeholders to be involved in this work and to provide their input on how we design, not just payments, but kind of all of the parts of, all of the parts of the Act 167 work, but the operations that will go into that, the potential impacts on patients, all of the things. While we are here on the slide, I also wanna mention that obviously this timeline goes beyond to the end of the fiscal year. So in committee discussions last year, we were very explicit that this is not the work of one year, this is not a one year process. This is the work of at least a few years. So the full dollar amount allocated in section three will not be spent at the end of this fiscal year. This is in part because stakeholder engagement is built into every process, but it's also because the work itself is just really technical, it's challenging, it's complex and it will take time to kind of do our due diligence there. As we're doing today, we'll continue to update you all on the full scope of this work under Act 167 as it progresses and we'll also be taking the necessary steps to carry forward funding to future years as needed. So getting back to that technical advisory group, I'm zooming back in here. As I mentioned, this work group is co-chaired by GMCB and AHS, two GMCB contractors will work closely together on this. Baylett Health and Mathematica will be supporting both the policy analysis and the quantitative analysis necessary to support the state and stakeholders through this decision making. I want to, it's not mentioned on the slide, but I want to mention last year and to kind of lead up to the passage of Act 167, a consultant for the legislature, Donna Kinzer, was one of the voices kind of recommending that we explore a move toward global budgets and global payments. Donna Kinzer is a subcontractor to Mathematica so we can continue to take advantage of her expertise and her ideas as we explore this. We're very lucky to have her as kind of the collection of experts that we are relying on to support this work. I've also included some of the work group membership here as you can see, it includes hospital CFOs, health equity representatives, payer representatives with a real focus on folks with technical expertise, actuarial staff and provider contracting. One care of Vermont is represented, their payment model development and finance staff are there. The office of the healthcare advocate participates with team members. We have a union representative, two providers and staff from across state government in areas that this work could touch. As you can see, again, really focused on kind of technical expertise because we're gonna be diving into the weeds here. So the materials from this group are being publicly posted as they become available and we'll also be cross posting them on the AHS website to ensure that folks can actually find them, which I know is not always as simple on our websites that we're trying. So between now and the end of 2023, we will be working through a series of topics fairly methodically and I've listed those here at a pretty high level. They include defining scope, baseline budgets, calculating those baseline budgets and coming to kind of methodologies for doing so, defining potential necessary budget adjustments which includes things like for trends like inflation or for exogenous factors like public health emergency as well as based on performance so quality, equity, financial performance and to mitigate risk. It includes payer participation, provider participation, strategies to support transformation, administering the program, setting budgets, things like that as well as valuation and monitoring which is definitely a last but not least that will be really critical. And now I'll hand it over to Sarah Lindbergh. Thanks Sarah, Sarah Lindbergh and I'm here to talk about our regulatory process evolution starting first and foremost with our largest lever which is the regulation of our hospital budgets. So on the next slide, you can see that as any classic Vermont project, it's not isolated or linear and there's lots of things all happening at once so we're doing our best to wrangle multiple work streams but some of the specific tasks in 167 that interface with our hospital budget regulation have to do with incorporating value-based payments or other global payments into our regulatory processes and while not highlighted here, I think equally important is making sure that we understand the effects of our regulatory processes on the financial sustainability of Vermont hospitals and thinking of potential opportunities to strengthen their financial status through our regulation. So just because the only half is underlined doesn't mean we're not paying attention to the whole charge there. And I think that the item three here is talking about an allowable growth rate for hospitals budget. So looking at national and regional factors, what sort of things can we look to to determine allowable growth rates and finally, what if any is the role of global budgets in our hospital budget process here? So those are kind of the relevant portions of the new statute. So on slide 17, just a very, very high-level, quick and dirty history of some relatively recent reform efforts. So 1992 is really when the new normal started and the Vermont Health Security was formed. That merged some separate bodies, the Health Policy Council, the Health Data Council, and there was also a board dedicated to the certificate of need process. So they came together for a short time under the umbrella of the Health Care Authority. That HCA part became Health Care Administration and was enveloped into the Department of Banking, Insurance, and Securities, which is when Bishka was born. If you ever hear someone talking about Bishka, they're now known as DFR. But that is when the state of Vermont established its authority to actually restrict hospital budgets. So that's the first time that while we had monitored it quite closely in the past, that we could actually do something about it from a regulatory standpoint. And 2011 is when that HCA part broke off and turned into the Green Mountain Care Board and DFR was renamed. So the review of hospital budgets is just one of the tasks that migrated with that change. So on the next slide, you can see that we have some ongoing duties that recur each year. So each year by October 1st, we set hospital budgets for our 14 community hospitals. We are going to be in fiscal year 24, also be doing a budgetary review of the Brattleboro Retreat. So we're starting to get that going. And we also have some financial monitoring obligations for the designated agencies and social service agencies. However, the global, I'm sorry, the hospital budget process is just for those 14 community hospitals. And there are several things that we buy to that you must consider, things like the local healthcare needs and resources, utilizations, that means what are people coming to which hospitals for and how often, looking at the administrative costs of our hospitals and as always gathering input from the public. If you have trouble sleeping or otherwise interested, you can look at our explainer about the hospital budget process. I'm also happy to chat with anyone if you're interested in a month or more detail about it. But I would say that one thing I always find really helpful and important to remember is that each of those hospitals has to get that budget passed by their local board which includes community representation. And that balance between state level and local control is one that's always important and can be delicate in Vermont. I heard a noise, didn't anyone else hear noise? Okay. I heard my throat. Oh, okay. Sure. All right. We'll move on then. So, on slide 19, I think it's important that this work to revisit and evolve our regulation of hospital budgets predated 167. It was already in flight. We knew that the process really had not had a large review since it was initiated in the 90s. And some of that actually started in the 80s. And so we had already put out an RFP related to a scope of work to look at our practices and make sure that they were streamlined and efficient and focused as possible. And the goals that we had, again, prior to 167 was determining some objective metrics for hospitals' financial health. We've done a good job of looking at relative indicators, but I think that we really have been lacking some official standards of financial health for hospitals. We also knew we needed to get more sophisticated in our evaluation of hospitals' performance. So really at a hospital level, what does quality access and efficiency look like and how can we better measure those things and in ways that make sense and have logical peer groups to compare with? We also always are looking for ways to better coordinate our regulatory duties. So for us, one humdinger is the federal calendar for the review of qualified health plans, which we do, and the state and the federal calendars that relates to a hospital budget. So trying to get those things to inform each other in a better way is top of my personal list. And that really being serious. I just want to interrupt you there because that's something that I had written down earlier. And if you have some recommendations to make around bringing the dates for rate setting and budget decisions together in some way that we might be helpful, please let us know because it's a consistent problem that we hear about from our payers and our providers. Yes. I really appreciate that support. And yeah, there's no easy answers here, but we will certainly be not shy about reaching out if we think of anything that might be helpful. I really appreciate that. And then certainly not least, but last on this list is looking at the feasibility of reducing the administrative burden. We know administrative costs are a big part of the problem in the United States healthcare system. So we want to be as focused and streamlined as possible and because resources are quite scarce, particularly right now. And this is the work that I kind of think about the Remount Care Board getting its house in order. Financial health theoretically should be agnostic to the way a hospital is paid. That's something that we should be able to measure and integrate a lot of these concepts with whether or not a global budgets are integrated directly or how soon. But, you know, that allowable growth rate for the hospital budgets and thinking about the appropriate role for global budgets in the hospital work again is related and worked into this, but it's a little bit not the core work of this kind of dedicated scheme for our oversight work, if that makes sense. So nothing's in a vacuum, but in my book, like getting this right and really truly evolving it needs to happen no matter what. And then, so these are like big essential questions that there are no easy answers for, but just to give you a flavor of some of the things that we're grappling with as a regulator, you know, how can we truly assess access affordability and thinking about meaningful outcomes in our hospital budget process? You know, what are the characteristics of a healthy hospital? What does that look like? What information is really about setting a budget, making those decisions versus what we need to monitor as a regulator? You know, a lot of these problems are much bigger than a hospital or even our hospital delivery system. So where is it more about monitoring and digging in as issues arise and what is it really fundamental to a hospital's budget? What are factors that really should be assessed at the hospital's corporate level versus individual hospitals? So, you know, to take a significant example, the University of Vermont Health Network has several hospitals, three in Vermont and some other facilities in New York State over which we don't have much leverage. On the flip side, we have organizations affiliated with Dartmouth. So, you know, when we think of through these questions, we also have some constraints. So even if it might be appropriate, it might not be possible. So kind of thinking through some of that optimization, thinking about appropriate benchmarks. I think we all are looking for those but making sure that they make sense for hospitals and for Vermonters and kind of figuring out a matched set of measures. So often one initiative might create an incentive you don't like. So how do you kind of hedge against that? So trying to balance that in our thinking of regulation and how many things even make sense to compare all 14 hospitals on versus other peer groups and here's where we're really trying to evolve other data sources to look for appropriate comparison hospitals, particularly for a state with only one academic medical center. What about those who either have a budget they can't meet or those that blow their budget? I think that to date our enforcement has been a little clunky. So thinking through ways to kind of integrate the enforcement right in with the regulations. So there aren't gonna be any question marks about what can happen if that should come to pass by any hospital. And maybe some of the most interesting thinking in the horizon is what about hospitals that I really feel prepared to take on significant risk? What's the regulatory role there? Is there like a limit to the amount of risk that's appropriate for a facility? And how can we think about the solvency of a hospital which is much different estimate if you think about some of the risk that we traditionally associate with insurers? So again, just a smattering of some of the small questions that we're trying to take off the list. This is not a census. There's many other things we're grappling with and that's again, just a flavor. So in terms of timeline, as I said, I've worked for the state for a while. So I think I'm a lot more realistic about how long some serious change can have. And so we're hoping that the real new piloting of these methods would be launched in fiscal year 25. So the hospital fiscal year goes from October 1st to September 30th, so it would be the guidance for that October 1, 2024 that we would be looking to make the most significant changes, but we have plenty of work for us. So in the upcoming guidance for the hospital fiscal year 24, we need to finalize that guidance by March 31st. And so we are working on getting that done and won't take any breaks. We'll keep working on guidance for 25 right after that. But in the meantime, we need to develop some performance measures, look at other data sources that we should be using, enhancing those monitoring systems for Vermont's healthcare delivery system, thinking about ways we can really focus that budget review and come up with standard analyses so that everyone can have a predictable process that is stable year over year. I don't expect us to get it right out of the gate and expect some refinement and more tinkering in fiscal year 26 and beyond. We do expect that there might need to be, certainly we envision a rule change will be necessary. I'm not sure if any other statutory changes will be part of the deal. We'll certainly be talking to you all if that's something we envision might be necessary. But I think that like any good process, there's a lot of feedback, the problems that Vermont and other systems are facing weren't created overnight. It's gonna take a lot of creative thinking across the spectrum to really kind of think through some of this evolution that we have in mind. So, yeah, I'm sorry, and I apologize for coming in late. And so I may have missed this, but through this process, are you, and I'm sorry, this is Lori Houghton, are you doing, I'm sure you are, but can you explain stakeholder engagement with the hospitals through this process? And if you already discussed this, I can take it offline. Oh no, not at all. I didn't talk about it specifically to this process. So that is going to be, so already the contractor Mathematica has interviewed all the board members here at the Green Mountain Care Board and has reached out to every CFO, Vermont hospitals, as well as the CFO for the Vermont Health Network. And the first pass is really just current state, what's working, what's broken, is there any low-hanging fruit we can knock out? So we're gonna try to incorporate that in this upcoming guidance. And then we really will kind of come up with some more ideas to triage with a broader group, because we know that these decisions also aren't happening in a vacuum. So that'll pick back up probably this summer. Great, thank you. Senator, I think Senator Hardy has a question, but I have a lot of questions and some of them relate to what we're talking about now. I'm gonna hold them till later, but Senator Hardy has a follow-up to the question we're just asked. Yeah, thank you, Senator Lines. Just following up on Representative Houghton's question, one of the things that I was very adamant about in our discussions about Act 167 last year and what I don't see very much at all in your presentation is the stakeholder engagement. And I don't mean hospitals. I mean, yes, we obviously want to have them integrated into the stakeholder engagement. They are a huge stakeholder, but I'm very interested in how you are engaging with patients and actual people and Vermonters who use our healthcare system. And I'm really unsure if Mathematica is the right consultant to be doing that engagement. That's not their strength, that's not what they do. So if your stakeholder engagement process is just with hospitals, that's concerning to me. Sure, and I didn't mean to imply it was just hospitals at all. And that's where our conversation with the healthcare advocate are quickly gonna go as well. I think that they'll be really good partners in making sure that we're getting direct feedback, particularly from healthcare consumers. We'll also be talking to independent providers to figure out how all this affects their lives. We're talking to commercial payers as well as Medicaid. A little bit harder to have much dialogue on this with Medicare, but we certainly do our best to understand their perspective. But I do think the concept of consumers' interactions with our healthcare delivery system and in particular, its affordability are much bigger than the hospital alone. So I consider us a piece of that framework that we're still working out. Okay, I guess I would love to have more conversations with you, Jessica Holmes and I were very, very aligned on this last year and the direction you seem to be taking it is certainly not what I had hoped for. And I think there's a little disconnect here. So often in Vermont, our healthcare reform leaves out a significant people and that is the people who actually have to go to the doctor and get healthcare in Vermont and they don't understand what you're doing or why you're doing it and we need to engage them more. So Sarah, let me ask this question because I have a lot of questions around the community engagement process as included in 167. Are you going to get to that in the second half? Yeah, I'm realizing that this is kind of confusing because again, this was kind of work that is related to 167, but again, began before 167, but the concept of hospital transformation is one that we know is going to be integrated in our oversight of hospitals and that's going to have significant engagement with the community. Are you presenting that today in your second section? Are you talking about the community engagement? Because I think that's what we're moving to as we listen. Yes, yes, absolutely. So I do just want to add that right now we've kind of walked you through the majority of Act 167, section one and the duties that fall to the board in section one. Section two really is the data informed community engagement process to support hospital information and that's where we're planning to take a little break for questions and then move on to that work if that's acceptable to the committees. Yeah, that's good. I mean, continue with your presentation. Obviously what you're doing has triggered a lot of questions about the work that we did last year and I think it's great. So we'll just keep moving right along. Madam chair, I'm trying to understand this is house human services. I wasn't sure if she was saying that now was the time for questions on this section. Sarah, is this the time for questions? She's got one more slide. Yeah, I can just wrap up here and we're happy to dig in. Okay, we have a question when you're done. Thank you. Okay, no worries. Yeah, I mean, I think I covered most of this honestly but yeah, again, this is a tangentially, this touches 167 and some of it doesn't but it's all interrelated and we know that there'll be a lot more to do with the community stakeholder group that we'll talk about in the next section. But yeah, questions, let's go. Okay, so I'm gonna start with a couple of questions and then I'll turn it over to Lori and to Teresa, Representative Houghton and Representative Wood who will each have our committees ask questions. But my question is around the data collection that you're doing, obviously it's a lot about budgeting but part of the, one of the goals here is to improve quality. So data collection around quality improvement and how is that going? Yeah, so I just connected with the Vermont program for quality and healthcare again yesterday and they had a framework that they developed with broad input. I think they landed on 19 measures that we will certainly incorporate into the quality review this year. I think it's important to note that there's a difference between the quality that makes sense for a hospital for what they've done and should be accountable for versus more broad system-wide quality. And for instance, if there are people showing up into the emergency department that maybe would have been better served in another setting that's not to necessarily blame a specific hospital but to look at what's missing or could be really dug into in those pathways to make sure that the right supports are available in the right place. So I think some of their future thinking will be not only modifying the hospital specific framework but hopefully helping us think through more systemic quality issues, if that makes sense. Yeah, thank you. And then I'll ask one more question and then I'll see who else has questions. But one of the issues again that we hear about consistently is around the predictability of data and information required for budget review and that it goes on and on and similarly for rate review. So as you're shivering off all of this information for hospital budgets and quality improvement, how are you informing the board about greater predictability and their requests for budgetary information? Yes, I think that's an excellent point and a good chance for you to remind everyone I'm really here to talk about a very narrow piece of this puzzle, which is the regulation of hospital budgets and versus the much broader 167 work. And so I've got kind of a very narrow piece to talk to. But I think in terms of setting those hospital budgets that the data has gotten pretty big, the asks have gotten big and maybe not as closely aligned to a specific budget. Not to say it's not important things. So I think one major process consideration is the right streams for data and making sure we're getting it from the right person. So for instance, while we can make a chief financial officer tell us about the equity initiatives at their hospital, maybe they're not the best spokesperson for that work unless there's a specific budgeted item that they're asking for. So I think that that's part of that broader evolution of how we kind of regulate our system and making sure that data's coming from the right places at a appropriate cadence. And if I might jump in and just speak more broadly to Act 167, we are taking care to make sure that we are presenting regularly to the board and providing the board, excuse me, as well as other stakeholders regular updates on each of these work streams. So for example, we soon after Act 167 was passed over the summer, we provided updates to our general advisory committee. I believe we also presented to our primary care advisory committee on this. So, Senator Hardy to your point, it's so critical to make sure that we are, that even on these first three work streams, which are not as much focused on kind of the broader engagement that we are communicating out and bringing in feedback and ideas about how we can improve this work. And so our advisory groups are one of the critical ways that we do that. And those do include, you know, Vermonters, Vermonters and consumers. So we're making sure that we're kind of presenting publicly as well as to those more targeted groups on a regular basis to make sure that board members and stakeholders in the public are informed. Okay, questions in the Senate room. Okay, we're good, we're good. Okay, go ahead. Representative Houghton or Representative Wood, do any of your folks have questions? We do have one here, Mari. Go ahead. This is Representative Cordis from Lincoln. Thank you for your presentation. I'm struck by having followed and been part of healthcare reform for a number of years, including having been on a consumer advisory council for the Green Mountain Care Board. What I'm hearing sounds like what we've already been doing and knowing that we have finite resources. And I apologize for the metaphors I'm about to use and use them often. And it feels like we're still squeezing the balloon. Quality is important. And I'm glad that we're moving towards value-based payment models and then to global budget development. But with outside pressures like at the federal or the national level, the federal level in the corporate world and in the government world, the cost of pharmaceuticals go at skyrocketing. It feels like we're squeezing the balloon still and trying to, hospitals and other healthcare institutions have already worked so hard since the Affordable Care Act and before to focus on quality measures and shrink their budgets. You know, go for that low-hanging fruit. That was the other metaphor as we use it. It feels like we've already picked all the low-hanging fruit. Tell me what's different that's gonna help us deal with the situation, especially things that we don't have control over. What I, so Sarah, maybe if it's okay with you, I'll kick us off. And then I'm sure you'll have better things to add. All right, so thank you so much for that question, Representative Cortes. And I think what I hear you concerned about is both the overall burden on hospitals and other healthcare providers in implementing reforms like these and how we can make sure that the work that we are doing here supports our shared goal of having healthy hospitals, having access to affordable, high-quality care for over-monitors in their communities. I think one of the things that as someone who has been working in this field since the Affordable Care Act was passed and through that implementation and kind of seeing that implementation and the challenges that you mentioned, one of the things that's really exciting to me about the work that we're doing here and specifically about that orange bucket, thank you, Julia, for pulling this slide up. And the global payment model development work is that I think one of the things that came out of the legislative conversation last year and one of the things that one of the kind of themes of our work and of the legislatures, all of your committees work over the past few years has been how can we balance our goals of access, affordability, high-quality care with the need to support a healthy hospital system and make sure that a critical part of access is making sure that we have sustainable and healthy hospitals. And so we know that that's critical. How do we balance that with our need to bend to the cost curve and to make care more affordable for over-monitors? Apologies if you can hear my cat meowing in the background the joys of working from home on a snow day. So sorry, so I think one of the things that really excites me about the global budget development work is that we see, and as our work on kind of the technical side of this with stakeholders gets kicked off, we see this as an opportunity to be able to build both of those goals into a payment model, which I think to date the value-based care models that have kind of evolved through this, that this would be a significant step in being able to balance both of those goals. Okay, we have one other question and then we'll turn it over to Representative Wood. Go ahead, Ari. Yes, this is a representative Peterson from Clarendon. I'm looking at your slide number 13, and that slide talks about your hospital global budget technical advisory group. And I'm wondering, first of all, has that group been established and has it met yet? And just wondering about the size of that group. Just get into the weeds a little, I know, but you can go. Thank you so much, Representative Peterson. This is a very timely testimony that we're giving today. That group met for the first time on Tuesday. And it has, I would estimate about 15 members. I wish I had a total for you right off the top of my head. I will say the membership is not perfectly established yet. We had a couple of folks miss the first meeting and for example, we'll be adding our hospital health equity representative at the next meeting. But yes, so we just kicked off this week and are kind of coming together with a really solid work plan for how we're going to tackle the issues that I think slide 14 delves into over the course of the year. So this is the group that's going to make this thing happen. I have what I'm trying to say, is that correct? The outcome of this group, I think toward the end of the year, right around probably December 2023, the state and the contractors that are supporting this group will kind of take the outcome of all of the discussions that this group has had and produce kind of a methodology paper based on that. And then I think that methodology paper will both lay out kind of all the technical details of a payment model, as well as talk through the steps toward implementing that payment model. I think one of that we're in a little bit of a chicken for the egg, which comes first situation in that some of the technical payment model details need to be figured out before we can really get to. So what does implementation look like? We need to answer some of those questions before we can think through the steps toward implementation. Okay, but this would be the group for us to kind of follow, to look at, to see what's going on with the redesign. Absolutely. And as I said, we've got materials from the first meeting posted to our website, which you can view at the link here. We're going to plan on keep, to continue doing that and the materials from each meeting will include a brief summary of the discussion of the prior meeting. So that kind of, so folks can really follow the discussion and kind of see where we're going. Of course, Sara and I are always happy to return to any of your committees to provide you with an update on how that work is going. Thank you. Representative Wood. Thank you, Representative Houghton. We do have one question here. Thanks, Representative Donahue here. And that was a great lead-in to a much narrower specific question I have on the technical advisory group because I understand why it has to be the people with the technical expertise. I'm glad the healthcare advocates involved from the consumer perspective and you can't have broad public participation in this. But I wanted to check, is this an open meeting in terms of people being able to sit in and see what's happening in the discussions? That's a great question. We haven't had, I don't think we've had anyone ask that question yet. So I don't have a perfect answer for you. My guess is that yes, as a technical advisory group of the board, it would be open. I think, of course, we are trying to balance openness and transparency. I really wanted to make sure that we are providing openness and transparency with having a space where it is comfortable for the stakeholders who would be involved in actually administering any new payment model and directly impacted by any new payment model to share their concerns about that. So I think I believe it would be an open meeting if anyone were interested in joining and we can share that information out with anyone who would like to join. Thank you. That's it here. Thank you. Okay, terrific. Thank you. Why don't we just move ahead to section two then of 167? And this just gets into the community engagement program and a little bit about transforming support services, care management, integration of acute care and subacute care, all those things that we're beginning to see an absolute need for improvement across the board. So up, there you go. All right, thank you all so much. And thank you for your excellent and just really thoughtful questions and discussion. So taking a minute here to kind of harken back to the beginning of our presentation, we're showing this visual again, which I guess was just up on the screen, just to emphasize again, the shared goals between all of these work streams. So this is really about ensuring an accessible, affordable, high quality healthcare system for Vermonters and how can we build that together. So diving into our, to the last but not least, final purple bucket here, the goal of task two is to better understand the current state of Vermont's healthcare system at a community level, as well as to support hospitals and identifying ways to keep them financially stable and sustainable. We really see this as the beginning of a statewide process to better understand our current healthcare land state and to brainstorm actions to move us toward the shared goal of ensuring Vermonters can access the care they need and that the system is financially sustainable. In other words, Act 167, we feel direct access to work hand in hand with providers and their communities to explore those various paths forward. So section two of Act 167 defines a community engagement process for hospital transformation and it's focused on reducing inefficiency, lowering costs, improving health outcomes, reducing inequities, ensuring increasing access, excuse me, and maintaining infrastructure for emergency management. We expect that work to include a really broad spot of stakeholders, including hospitals and providers as well as payers of the state and importantly Vermonters and their communities. And we expect that engagement to touch every region of the state. So this slide, this next slide provides, thank you, Julia, a quick timeline. So over the spring and summer, GMPB worked very closely with AHS to develop an RFP scope and I should have spelled that out here. That's request for proposals. In a minute, we'll take a little detour into the state contracting process, which I know everyone will look forward to and kind of describe how we get there. But we worked very closely with AHS to develop our request for proposal scope and to vet that with stakeholders. It is really, in my years in state government, I have never done that in the midst of the contracting process to actually bring a draft scope of work out to stakeholders and get feedback on it. But we really thought in this scope in particular, it was critical to make sure that we had input and buy-in from the beginning and that the scope we procure for is the right scope. As a reminder, we talked earlier about kind of sequencing stakeholder engagement of this process so that it's coordinated but that we minimize burden. And we've tried to highlight that engagement here. I didn't include this in the table, but GMCB's hospital budget process, as Sarah mentioned, also occurs in August and September. So this is a time when we wanted to be careful, as careful as we could about potentially overburdening our hospitals and our healthcare providers. We're currently in the process of getting a contractor on board for the scope of work and I'll talk about that again momentarily. But I just want to say the last key date here is contract execution, which we're hoping to do late March, early April, and that's when the work would actually start. So another quick detour, we weren't sure that all of you would have experienced the state contracting process in all of its glory before. So we wanted to just quickly give you a sense of the steps here and also the length of that process. I'm not sure how this lines up with other agencies contracting experience, but we are really mindful of the resources, both financial and human, that it takes to execute and manage large contracts like this one. We put a lot of effort up front to ensure that we're very clear about scope when it comes time to launch a request for proposals and to actually execute a contract. And there's really robust staff leadership involvement at GMCB to ensure that we're not duplicating efforts within our department or with other state agencies. And that's kind of in the normal process. I want to distinguish that standard state process, which to be clear is slow and it's slow for a reason. With the additional work that we did here to ensure that stakeholders were really thoughtfully included in building that scope. And then we were minimizing the burden on stakeholders whenever possible. So, as you can see here, and this is kind of adapted from the requirements that are included in Bolton 3.5, we're looking at five to six months to kind of select a contractor and then another probably four before we have a contract signed. It is not a quick process, but it's really important that the state's policies keep us to a really thoughtful bid review and contracting process. And it helps us arrive at a better product in the end. So this slide, probably in a little bit too detailed of a way, very kind of like RFP speak. It walks us through what is the scope of that request for proposals that is out there right now. A reminder here, the ultimate goal is to ensure that Vermonters can access high quality care in their communities and that our system is financially sustainable. And so this request for proposal scope is about, how do we get out there in communities and work with communities and work with hospitals and their boards and leadership to figure out where we go from here. Again, this is the start of the process. The contractor will do quantitative and qualitative data collection as well as funding allowing provide some technical assistance to hospitals to develop transformation plans. Diving in a little more deeply, task one is the statewide and community specific analyses or data profiles utilizing the existing now as much as possible. An example of what task loan might produce could be demand modeling, which projects into the future or our population and our population's healthcare needs so that we can see what kinds of care might the people in our communities need five or 10 or 20 years in the future and what kinds of healthcare providers and infrastructure do we need to ensure are available to them at that time. Task two is engagement in every health service area. This is the qualitative data collection, but it's also sharing out the data that we compile or analyze in that first task so that communities have a better understanding of the local landscape both now and what is projected. So Senator Hardy, I think that this is the work that you and Jessica Holmes kind of discussed at length last year, last session, about how making sure that we are not just consulting with hospitals or their leaders, but that we're consulting with individuals who are seeking care, who are going to the doctor, who are purchasing health insurance, who are owning businesses in their communities. Thank you, I'm reading the RFP now. My condolences. Meeting about. Task three is really about asking what now? So now that hospitals and communities have the information that we've collected through tasks one and two, where can they go and how can the state help? In this task, to the extent that funding allows, the contractor will be providing more intensive technical assistance to hospitals to actually help them develop actionable plans for transformation and will be facilitating a group learning collaborative so that participating hospitals can learn from one another. We had estimated in the RFP that this work would probably include a small handful of hospitals. We, I think we estimated for in the RFP who would participate in this process voluntarily. I do want to note that funding for direct technical assistance to hospitals was kind of considered in the process of Building Act 167, but wasn't included in the final budget. So this is something that we want to do within the current budget, if at all possible, because we and I'll say, we GMCB and AHS really believe in the importance of this work and in making sure that hospitals have the resources to develop solid plans in the future. Just a comment here. I think I'll let you continue. I'll make my comment at the end. Sure, thank you. We are really close to, I think this is the next slide is the last in this section before we have time for questions. So again, that was really, the previous slide was really an RFP speak, but we wanted to kind of lay it out in phases for you. Here you can see more of how this plays out, we hope. You'll see here that the data analysis and the broad community engagement tasks are really focused in the first phase of this, of this contract for six months of the two year contract. So that work we'll need to get underway really quickly. And our goal is to be able to leverage the findings from those early phases and get the technical assistance and kind of on the ground work started as soon as possible. Again, budget allowing so that hospitals can have that expert support and technical assistance and really kind of move on the information that we learned from tasks one and two. And those are, that's all I have for, as for slides for section two. So we wanted to open it up to questions again. And then we've got a couple of reference slides at the end in the event that we need them or they're of interest. Sarah, thank you. It looks like a Herculean task in putting those two things together. We understand that, but the value of having Green Man Care Board work with AHS has been really important to the process. And I appreciate that work together. And I did look at the RFP in the summer and took a lot of work to put it all together. I did want to comment briefly that this interest in community support and hospital continuity of care from acute to subacute, we've been at least by interest over the past several sessions in having continuity of care for patients. So we don't think about each of these institutions as separate. You go from the hospital to the nursing home, from the hospital to the counseling services, or vice versa. And we're a little state, so having a small population but that rural environment, this is an opportunity for us to really assess the needs. And I'm so pleased. I personally am very pleased that the work that you're doing with AHS is continuing, so it's awesome. So I will turn it over to folks for questions. You have a timeline up there that, for me, looks pretty aggressive to get all the data and all the information and work with all the communities. How confident are you about that timeline? That is a great question. That is definitely one of the pieces of this work that keeps me up at night. I agree that the timeline for kind of the first phase of that contract is really aggressive. So I would not be shocked if we end up moving a little bit more slowly than we'd hoped on the data and broad community engagement work that will kind of touch all of the health service areas. I wouldn't be shocked if that slipped a tiny bit, but I think the takeaway is that we'll really be focusing that in the first phase of the contract and working to kind of move into technical assistance and be able to actually leverage that data to help hospitals take the next steps with it as soon as we can, funding allowing. Yeah. Good luck. Thank you. Questions in this committee? OK, good. Thanks. This is great. I think you've answered a lot of the questions that we had earlier. So Representative Holden and Representative Wood, it's all yours. Great. So we have two questions here. Leslie and then Mari. Yeah, thank you for this work. It's really interesting, but it is a long haul project. I was wondering how the legislature can support this work as ongoing, and I think I heard you say something about money for technical assistance for hospitals, which I think might take some burden off them. And I'm wondering if you're going to be making an ask that we can think about and work with at some point. Thank you for that question. We are not planning on making an ask. We're really hoping, well, last year we tried to come before you and present an ask that was really inclusive of what we thought we would need to kind of get to operations, I guess. It became clear as we were developing the scope of this RFP over the summer that we really did think that the technical assistance for hospitals and helping, not just saying, here's the information, do with it well, but kind of working closely together to take the next steps and say, OK, so what now? It was really important. We are hopeful that we will be able to do kind of the full scope of the RFP and the money that was allocated. But thank you for bringing that up. And we'll kind of take that back and give it more consideration if it becomes clear that we're not able to complete everything we'd hoped to. Yeah, I'm actually thinking about from the hospital end. I'm worried about burden on hospitals. There's a lot already for them. So yes, I get your work, but I want to protect them too, I guess. Absolutely. Thank you. And yeah, that's certainly our focus too. And it's why we want to be able to kind of provide funding to take the next steps for a cohort of hospitals who are interested and kind of ready to engage on that. Thank you. Mary, and then we do have Topper. And then we'll give Representative Wood time to have questions. Thank you. I'm looking at slide 27, back to community engagement to support hospital transformation. And I'm wondering for this aspect and any other part where you included stakeholders in planning and evaluating, you included organizations that represent two different groups of professionals. One is frontline workers like nurses, physical therapists, occupational therapists. So organizations that represent frontline workers who all of this work eventually does filter down to most of it. And then the other group would be a group that represents pharmacists. They are in my work with pharmacy benefit managers. I've come to have a huge amount of respect for the work that they do and the role that they play in our health care system, including the knowledge that they have about ways to reduce the cost of pharmaceuticals in Vermont. And they have some brilliant ideas about how the role that they might play in clinical spaces. I'm actually speaking outside of hospitals now, but I still wanted to get that suggestion to you. So thank you for listening. Thanks, Maureen Tupper. This is the representative of McFawn. I was wondering if you could help us understand how the hospital in New Hampshire dot myth and how the hospitals in all of the eights, what role, how do they fit into this whole thing? Do you have any oversight at all over them? Yeah. So I'm troubling in many legal domains that geography doesn't always make the most sense. But yeah, our constraints are limited to things that happen in the state of Vermont. And so we're thinking through, and for me, it's really about financial health, like what makes sense to evaluate at Porter Hospital versus Central Vermont Medical Center versus the University of Vermont Health Network and trying to figure out the right sizing of the measurement and assessment of those things. On the flip side, I could ask really nicely and maybe Dartmouth would share something with me, but they don't have to. So I'm going to be looking at hospitals that are affiliated with them, but might not have the privilege of seeing the so-called mothership, which is one of those constraints that hopefully we can build. And as we realize that care patterns don't respect state lines, that we can come together. But as far as forcing, we're pretty limited. Great. Thank you. But I think to your point, and Sarah would probably answer this better or with more detail than I can, I think to your point, we know that Vermonters are accessing services across state lines, particularly in the eastern half of the state all the time. We have significant outflow to Albany. We also have significant outflow to Boston. So we know that it's really important for us to consider kind of how does Vermont and what is within our control fit into the larger picture. And I think that's important in, that is going to be a really important consideration in our payment model development work as well. Great. Representative Wood, we'll turn it over to you. Thank you. We are all set here. Wow. That's great. Okay. Any last comments? So we're gonna take a little quick break, but any last comments that you would like to make, is there something you wanted to add from the board perspective? This is me in my very narrow role, but we talk about how healthcare in Vermont is a village on fire. It's a nation on fire. The whole hospital sector is in real trouble right now. All three rating agencies have downgraded its future. It's a big deal and a lot of these problems are not unique to Vermont. So I would say that it's a time where we have to change and it's also a hard time to make change. And so I appreciate everyone's understanding of some of these truly difficult to manage forces on all of us. I mean, I just saw a dozen exit price chopper for over $9, like it's bananas out there. Like, so anyway, I just want to be clear that Vermont's not the only state who's dealing with some of the biggest. And to that reminder, go ahead, Chef. And we'd be remiss if we didn't mention that last week's Green Mountain Care Board meeting, we had two presenters with national expertise on hospital sustainability and particular rural health systems speak to us about kind of how Vermont fits into the national context there. So I know two of your committees joined at least part of that meeting last week, but for those who weren't able to make it, highly recommend seeking out those presentations from Mark Holmes from University of North Carolina and from Eric Schell, who are both really kind of brilliant national minds thinking about these issues and giving some context to how Vermont looks in comparison to the nation. Yeah, thank you for that. We did get the invitation, but we're a morning committee, so we can't officially be there in the afternoon, but we'll look forward to looking at those little videos, it's great, thank you. And we are part of the national team, but I think what you're doing now as you follow Act 167 is going to, maybe we'll make some headway with this one. Let's hope. Okay, so Alex, I'm going to ask that you take us offline and we will be back at... Rest there. Are we good? So yeah, I think Alex is doing all three committees. So we can... Thank you very much. Yeah, we're offline and we're going to take a break. That is for all.