 Good morning and welcome to the Green Mountain Care Board. I see that members Lunge and members Pellum are present, so we have a quorum. So I'm going to convene the meeting and ask for the executive director's report. Thank you, Mr. Chair. Very briefly, I wanted to remind folks to take a look at our upcoming schedule for the rest of October. We have some extra meetings, whether it's the primary care advisory group or the general advisory group. And then I also want to remind everybody that on October 27th, we have two meetings starting in the morning at 11. I hope I have that right, I think I do. Yes, at 11 a.m., we're going to hear from some of our, a couple of our contractors that did work on the sustainability planning that is a report that's due at the beginning of next year to the legislature on hospital sustainability. So the titles of the presentations may not make folks realize that it is related to the sustainability planning. So I just wanted to remind everyone on that. And I would hope that many folks attend those sessions. I think they'll be very informative for all. And that is all I have to report out today. I'll turn it back to you, Mr. Chair. Thank you so much, Susan. So really the purpose of today's meetings is to talk about an issue that has been of grave concern to really all Americans. And what we've seen is that prescription drugs, especially if you take a look at the rate violings for the insurers, have been a primary driver of cost increases. And we constantly hear stories about Americans who can't afford their drugs or who are not taking the prescribed amounts of the drugs and things like that. So this is such an important topic. And it was so important that we created a prescription drug advisory group, basically trying to find out if there was anything that Vermont could do, knowing that we're not the country. But we are a state and we need to do anything and everything that we can do to make sure that our citizens have access to affordable drugs. And in that vein, board member Robin Munch and Christina McLaughlin from our staff have been conducting a series of advisory group meetings split into two. And so for the purposes of this morning, I'm gonna turn it over to Christina and Christina can introduce Nate, but also tee up the conversation for this morning. So Christina. Thank you, Kevin. So hello everyone, good morning. My name is Christina McLaughlin. I'm a health policy analyst here at the Green Mountain Care Board. And as Chair Malin said, I staffed the prescription drug technical advisory group. And board member Robin Lunge is that dedicated board member for that group as well. Before turning it over to Nate, I will just wanna provide some further background. Chair Malin really did kind of encompass the main points, but for some further background, during the 2020 legislative session while legislators were discussing how to address rising prescription drug costs. There was a bill proposed H785. It was proposed by representative Sarah Copeland-Hanses. So it was an act relating to the Green Mountain Care Boards Authority over prescription drug costs. At the time, unfortunately, the ask of the bill was not quite feasible for the board and therefore the board ended up proposing organizing a prescription drug technical advisory group. The timing was not great. The day that we proposed this was the same day we went into lockdown due to the COVID-19 pandemic. So therefore the proposal was put on pause in the legislature. But as Chair Malin said, given that the board consistently sees prescription drug costs as a major cost driver in our healthcare system and we actually have existing authority to create technical advisory groups to support the board's work, we ultimately decided to convene a group of stakeholders to create the prescription drug tag. The complete list of advisory group members is posted on our website, but overall the group includes representatives from the AG's office, AHS, DFR, Blue Cross Blue Shield and MVP, VOS, DEVA, Bi-State and UVM Health Network and two pharmacy reps as well as two reps from Vermont League Lab. The group held its first meeting in December of 2020 and since then, the board's prescription drug technical advisory group has been meeting to discuss potential state level solutions to address the rising costs of prescription drugs. To expedite that work, we created two subgroups, one focusing on out-of-pocket costs and another focusing on PBM regulation and those groups have been meeting for months. They've been doing a lot of great work and we are very, very thankful for everything they've been doing. Today we are here specifically to hear the recommendations from the out-of-pocket cost subgroup. And I just wanna quick note that all the materials related to this group are posted on our website and if folks have any questions, my email is on that page as well and people can reach out if they have any questions at all. So if there are no comments or questions at this point, I'll just turn it over to Nate. Great, thank you, Christina. Thank you, Chair Mullen and the members of the board for the opportunity to present our work here. Just give me a second and I will put my slides on the screen. We have success. All right, that's what we'd like to see. The slide deck is presenting. All right, give me one more second. No matter how many times I've done this, it never is perfectly smooth. And once it gets in that presenting mode, it's tough to get out of it. Right, right, maybe this will work better. You can let me know when you see it. Yep, we do, it looks great. Perfect. Okay, so my name is Nate Oritch. I'm the Director of Pharmacy Supply Chain for the UVM Health Network. This presentation reviews the work of the out-of-pocket cost subgroup. As Christina mentioned, this is a small group that's focusing on a specific subset of the various opportunities and ideas and problems we discussed in the full technical advisory group. I will note that the recommendations we make here are on behalf of the subgroup. They don't necessarily represent my opinions or the opinions of my employer. And there is one slide in here that we have added at the request of the Health Care Advocates Office. So when we reach that slide, I will turn that over to Sam to present. That particular slide has not been reviewed by the whole group, but was added at the Health Care Advocates request. So we started out as a subgroup by trying to understand specifically what problem we were trying to address. And these bullets basically distill down what we thought we would try to fix and what problems for monitors we're facing. First, it's that rising out-of-pocket costs, especially for high-cost drugs, prevent people from accessing treatment for the conditions that they have. For patients who don't qualify for Medicaid or for extra help with Part D costs, there are very few options to get assistance. And of those options that are available, some of them, like discount cards and manufacturer group bonds, charge pharmacies high fees and commercialize patient data in ways that patients may not expect while really providing pretty limited savings and increasing costs to the healthcare system as a whole. So what we tried to do was to just throw every idea that we had at the wall. We got a group of really smart people together, all of whom know a lot about the situation with prescription drug costs in Vermont. And we said, what are all the things that we could possibly try to address? And then let's dig into the details of each of those possibilities and then try to distill out from those what recommendations we think we can make that would meaningfully change the circumstances for Vermonters. And we came up with a small handful of topic areas where we felt we could offer recommendations. That includes the Healthy Vermonters program, the state's current out-of-pocket maximum rules situation we find with manufacturer assistance programs, the idea of a resource hub for patient assistance programs that exist in Vermont, an effort to improve the subscription of people who are Medicaid eligible to Medicaid assistance and enhance wellness formulary. Some work we have identified as being necessary around the pharmacist substitution on therapy class and then finally at the request of the healthcare advocates modifying eligibility requirements for the Medicare savings program. So I'll start with Healthy Vermonters. And the caveat for Healthy Vermonters is that we had pretty healthy debate between the members of the committee on what we could do here and what the right approach was. So while for most of the topic areas that I'll review here, we have a recommendation at the end. We don't have a recommendation specifically for the Healthy Vermonters program. We have several options, each of which was supported by the majority of the members of the group. So the Healthy Vermonters program that currently exists is a contracted discount program. It means that if someone who is enrolled in Healthy Vermonters goes to a pharmacy and uses their enrollment to try to obtain a discount on a prescription, the pharmacy charges the customer, the contracted rate, but the state who sponsors the Healthy Vermonters program does not pay anything. And so what we found is that this provides a pretty limited benefit to the small number of Vermonters who are enrolled. The discounts are modest. They're not necessarily as aggressive as discounts that are available through other programs like GoodRx for instance, and a pretty small number of Vermonters in general are using these on an annual basis. We will note here that the eligibility for this is limited to 350% of FPL or 400% of FPL for members with Medicare coverage. So our first option, and generally we all supported this option, even though it's not potentially as effective as the other two, is to improve the existing Healthy Vermonters program by expanding its eligibility to cover more Vermonters by adjusting the reimbursement level to become more competitive to offer a more significant discount. And we think that this is better than the current state. It doesn't cost the state any money. It makes the program at least as good as GoodRx and other potentially competing or other available assistance programs. It gives us a little bit of control over how patient data is used, which for some of these other cards out there is not the case. And I'll just digress on that for a second. When pharmacies take one of these programs, these programs that GoodRx I'll use as an example again, charge the pharmacy a fee. And those fees can actually be pretty high. There are eight, $10 subscription sometimes more. And the way that these companies make money at first is by charging pharmacy fees. And then it's by selling the data that they get. They get all the patient data, all the drug data, the pharmacies data, everything that comes through the dispensation of a prescription ends up being piled into a commercial database, which they can then resell for multiple uses. Of course, they de-identify the data when it's sold, but nevertheless, it represents potentially a use of patient data that the patients necessarily haven't reviewed or considered or approved of. So there is a benefit in having a state-managed program for this, where we have some control over how the data is used and over what fees are charged to pharmacies. Option number two is adjusting the Healthy for Moderners program to be a funded benefit. This does require legislative changes. It would provide a more significant benefit to the patients who are enrolled. Enrollment would still have to be limited based on the funding that the program has afforded. And it could also be targeted to patients who wouldn't necessarily qualify for other sources of assistance so we could raise the threshold. And it's clear that a funded benefit or a benefit that provides direct assistance to patients has more meaningful assistance involved than a simple discount program like the existing Healthy for Moderners program. And we did discuss a couple of different funding resources for this. The first is that the funds could potentially be raised through 340B Eligible Hospitals in Vermont. And we discussed how hospitals would react to this. The fact that the 340B dollars are pretty much already spent at all the hospitals. I won't go into my own perspective on that in great detail, but for each of these, there was definitely a range of opinions on how these funding options made sense. The second funding option was that it could be funded by DEVA with limited benefit from state dollars that some of these dollars could be raised through taxes and fees paid by drug manufacturers or additional fees charged to those drug manufacturers. It's unlikely based on the structure that we discussed that there would be voluntary external funding resources for this type of a program. We discussed, I mentioned some of these already. This is certainly an administratively complex approach. It does have the likelihood of some resistance from hospitals in Vermont. All the hospitals in Vermont are 340B Eligible. So this would incur some costs on those hospitals at a moment when the tolerance for those costs is pretty low. Like all assistance programs, the risk is that it desensitizes members to drug costs, removes incentives for making better consumer choices about which drugs to choose, thinking about things like generic substitution, et cetera. And then option three is similar in that it is a direct assistance model where patients receive not just discounts but direct assistance with the cost of the drug. And this relies on contract pharmacy. So we would use the 340B Eligibility of Hospitals and the contract pharmacy networks that have already been developed to offset the cost of copays and coinsurance and non-covered drugs. This again is somewhat complex. It's very similar to the type of assistance programs that some of the hospitals in Vermont already offer as well as the FQHCs offer a similar benefit. So it's a model that we understand and that we employ. I know at the UVM Health Network, we enroll several thousand people a year into a program that works just this way. Some of the limitations are that enrollment would be based on the relationship between a 340B entity, the prescriber that wrote the prescription and the patient. So only prescriptions that are 340B eligible for at least one covered entity in Vermont would qualify for assistance under the program. And those are some of the cons. You know, on the pro side, there's no expense of taxpayers. There really is no significant expense to 340B covered entities. That might be hard to understand but that is what we see when we implement these programs is that the savings that we see through contract pharmacy discounts are sufficient to offset the cost of the assistance that patients receive through the program. We believe that the majority of Vermonters are covered by that type of relationship either from a primary care physician that's employed by 340B covered entity, whether it's a clinic or a hospital or receiving specialist care through a specialist with the same type of relationship. We could potentially expand the coverage of this to more Vermonters than the current income restrictions would allow. There are some challenges with this because it leaves patients of independent providers who do not see a prescriber that's employed by 340B covered entity out of the program. That is a significant limitation for pharmacies that decline to participate in contract pharmacy. They would also potentially not be able to serve their patients. So some patients may have a desire to access the program which might persuade them to use a different pharmacy or even a different provider. So we anticipate that there would be some folks who would object to this model on that basis. And indeed those objections were raised during the course of the out-of-pocket groups discussions. So moving on and I'll go through these and then people can feel free to ask questions or Christina if there's a different approach you'd like people to take, that totally works for me. So we talked about the current state of out-of-pocket maximum rules in Vermont and our recommendation was to simplify and streamline some conflicting and difficult rules. Specifically we think it might make sense to unify the different out-of-pocket maximum caps understanding that holistically the burden of healthcare costs is broken out into multiple categories and all those categories need to be addressed as a whole. So unified cap for all those different types makes sense. We also suggest that we consider a monthly cap for those because there's a barrier to access and care if the out-of-pocket annual maximum is $1400 and all of those expenses incur for you in the first month of the year. That may present too high a burden for you to obtain your medication or your other medical care. So converting that to a unified cap might make sense for patients and for their budgeting purposes. We do know that there are some potential challenges with this from an actuarial value perspective as far as metal levels that will require some investigation and some recalibration. And this is broadly true for all the recommendations that we make that there is further investigation necessary for many of these and this is definitely one of them. And we discussed that with Christina and with member lunch in our last meeting that one of the things we want to do next is to investigate the specific impact that some of these options will have on Vermonters and any downstream effects that they may have. We will certainly need the assistance of the analysts at the Green Mine Care Board to do that. Next, we wanted to address some of the challenges with manufacturer assistance programs. I mentioned some of those challenges earlier that there may be an opportunity here for regulation to rein in some of the abuses that we see around these programs that it probably makes sense to start at least by collecting information. There are a lot of different coupon programs out there. They are generally prohibited for use with CMS funded benefits. So patients who have tricare, Medicare, Medicaid are not able to access these coupons because the federal government has decided that they are essentially disadvantageous to costs of the plan. So collecting these data points through mandatory reporting is probably a really good starting point with the long-term goal of preventing negative financial impact on consumers through the built-in preference for brand drugs that these manufacturer coupons have for folks who aren't familiar with manufacturer coupons. They virtually only exist for branded drugs and often case newly released branded drugs to try to make patients essentially cost insensitive because as plans develop their formularies, they may say for if there's six items in a particular therapeutic category, three of them are brands, three of them are generics. One of those brands is three times as expensive as the others. They will break those into cost share tiers in order to guide patients and providers as to which might make the most financial sense. These coupons break that tiering process. And so all of the plan participants in our out-of-pocket cost group made that point very strongly that there's a negative effect on plan costs associated with these coupons. And we also think it would make sense to address the patient health information element for these manufactured coupons that I mentioned earlier and there's the risk that these coupons, patients rely on them and the coupon programs can be suspended without notice which sort of leaves patients in the lurch potentially having to find a therapeutic alternative. In general, we think that there's a lack of knowledge among Vermonters about what different types of assistance is out there. So we think a simple solution is creating a centralized resource for what those different programs may be, whether it's a website or a publicly available database, perhaps through 2-on-1 or healthcare advocates hotline. There are a number of programs. There's the program I mentioned, UVM health network. There are similar programs at FQHCs. Many hospital programs are out there that provide assistance as well as the manufacturer programs and coupons and foundation supported programs that we've talked about a little bit here. So the resource would provide general audience information about what sources of assistance are available and how to access them. And we think that that would be very valuable. We talked about ways that we could help get patients in Vermont who are or maybe Medicaid eligible to enroll if they haven't enrolled already. We suspect that there are some of these folks out there. We don't necessarily know how many there may be. Nancy made the point, Nancy Hogue from Diva made the point that Medicaid does a fair amount of work around this already. But our belief is that there may be more opportunities. So we suggested raising awareness of the healthcare advocates hotline that helps people engage with coverage resources, including potentially signing up for Medicaid, expanding ways to outreach to eligible individuals using potentially matching funding. We talked about the successes and drawbacks of the navigator programs that have existed in the past and whether that may be something that's worthwhile to invest in. And then looking at easier ways for individuals to enroll in Medicaid, whether through tax forms or something else that they're already using. Here's some detail on this. I won't cover it, but you've all received the slides. I think, so there's a lot to review here and a lot of different points we came up as we discussed this topic. So for this slide, I will turn it over to Sam from the healthcare advocates office to review. Sam, are you there? Yep, thanks Nate. Good morning everyone, happy Friday. So this is a, as it says in the slide, one suggestion that we have as the HCA is to modify eligibility requirements for the Medicare Savings Program. This is a relatively straightforward recommendation. So basically this would be proposing to raise income limits for MSPs. So the current eligibility limits are 100% of FPL and then I won't read the whole thing. Really, so Vermont actually has a lower income limit than some neighboring states in Connecticut and DC are in our view the best models for consumer affordability. So there are a number of pros to this recommendation. So this would significantly lower the cost of services and prescription drugs, Vermont Medicare beneficiaries. There's definitely a myth out there that some folks believe that once you're on Medicare really a lot of your costs are contained and that's simply not true. There are many folks that are really struggling with high costs and lack of affordability in Vermont. So focusing on the prescription drug benefit just as a bit of background, if someone's on an MSP, they automatically get deemed eligible for another program called LIS, the low income subsidy, which is also commonly known as extra help that helps folks pay for Part D premiums and keeps co-pays low. This is a fantastic affordability program and more of Monters would receive help with Medicare premiums and cost sharing, which is a big issue that we hear about a lot. In terms of cons, I mean, like most recommendations but not all there would be some costs to the state, although this would be partially offset with the federal match. And if folks have questions, feel free to reach out or ask them and I'll turn it back to Nate. Thanks, Sam. So the next two are areas where there has been engagement by the state on these two topics in the past and we think that that's right for further engagement. So the first is the unused drug repository. So some movement happened on this several years ago. There was an investigation into whether a state program for collecting unused drugs for reuse might make sense. There were some economic challenges with it at that time. We certainly know that there's a huge, huge amount nationwide of unused prescription drugs that go to waste. The estimate, I think in this estimate is probably several years out of date is that it's at least $5 billion worth of prescription drugs in each year. So there was some legislation passed and signed by the governor at the time to dive into this and to create some movement. We think that the options around this may have become more economical since 2018 and that it's worth revisiting. So there's a vendor that helps states implement these nationwide. It's called SafeNetRx. So our recommendation here is that we reengage with SafeNetRx and to see if the options here have become more economical or if there's a different model that we can implement that may use some of these unused drugs in a useful way. And then the next one is pharmacist therapeutic substitution. So Act 178 went into effect last year and it intends to allow pharmacists to make therapeutic substitutions at the point of service for patients. And this differs from the generic substitutions which have existed for a long time. A generic substitution is between a brand and a generic item that are absolute bio-covalent. And pharmacists can and often do in many states are required to make those generic substitutions when a generic drug exists. But a therapeutic substitution is when a generic does not exist but there are other equivalent drugs in the same therapeutic class that may be equally as effective but a lower cost. So the legislation attempt to allow pharmacists to make those substitutions to comply with potentially payer formularies or other requirements into lower out-of-pocket costs and planned costs in general in Vermont. The challenges are that some of the restrictions embedded in the rule make it unlikely that this will begin happening under the current structure at a particularly high volume. Certain things are required like written provider and patient consent that just make it not really any easier than the old process of calling a provider's office and having a drug changed over the phone. So there are some opportunities to facilitate the implementation of the intent of this legislation. There are some things that bear investigation like whether we can use different elements of the search grips interface for electronic prescribing to automate some of these different steps. And we think that this bears further investigation if, and I think this is true, we want pharmacists to be able to use this opportunity meaningfully in a way that actually helps patients and reduces essentially the drag that attaches to the dispensing process when you have to return to a provider's office for an authorization or to have a prescription changed. So the remainder of the slides, I won't review, but they are included in the deck. These are topics that we discuss that we think are interesting, but that may have other efforts that are in the works or for some other reason, not particularly right for us to make recommendations at this particular time. So those are all the slides I have. I'm happy to take any questions that any folks may have or dive into the details on any of these people would like. Kevin, before we do that, I wonder if I could just do a quick sort of process update to close the presentation before we open to questions. That would be great, Robin. Great, thank you. So we did bring these suggestions to the full prescription drug technical advisory group. It's the full group meeting, which was earlier this month. There was no objection by the group to moving forward the recommendations from the subgroup to the board and potentially to the legislature. Mike Fisher, the healthcare advocate head indicated at our meeting that the legislative task force on affordability was hoping to get affordability suggestions by their meeting on the 28th. And so I think because of that, in my mind, it would make sense to allow the recommendations to move forward, assuming the task force, of course, is interested and wants to schedule a presentation on it, but have them move forward to the task force, which would also help give us a little bit of legislative feedback in terms of areas that they may be more or less interested in. As Nate noted, it was not really feasible for the subgroup to come up with specific number of people impacted or cost estimates. Those likely, in many cases, will need the assistance of DEVA or AHS to do the cost estimates. So that's work that we're gonna continue to talk about, but I think it still would make sense to keep moving things forward in the meantime, so that come January, we can have ducks in a row should the legislature choose to act. Super, thank you, Robin. That's very helpful. Nate, I'll start off some of the questioning. Could you just go over for us on the board? What would disqualify a pharmacy from being qualified to be a participant in a 340B program? There's nothing that would necessarily disqualify a pharmacy from participating, but some pharmacies may choose not to. It does place an administrative burden on pharmacies. Pharmacies may have other reasons to object to the 340B program. They may not necessarily have a great relationship with a local hospital or they may not be able to come to terms with a 340B covered entity that they find to be financially advantageous for them. So it's not necessarily then a particular pharmacy would be excluded or barred from participating. It's just simply that some may prefer not to participate, but that being a participating pharmacy in this version of the Healthy Vermonters program would require them to participate in to make that choice. And do we know what the participation rate is today? I think it's actually very high, maybe 100% or close to it with the existing Healthy Vermonters program, because there's very little burden on pharmacies from participating in that. I don't see any reason why any pharmacy would have declined to participate. As far as how many are participating with contract pharmacies, it's the vast majority of pharmacies in Vermont, I would say it's probably better than 95% of retail and especially pharmacies in this state. But there may be some who have chosen not to and in general, there are a couple of chains, Costco, and price shopper that have so far not yet broadly implemented contract pharmacy programs, and then there are several independent pharmacies in the state who have chosen not to. Do you think it's a cost barrier for the independent pharmacists or? You know, I've been involved in contract pharmacy for better than 10 years and part of what I do is negotiating those contracts with pharmacies and we generally look to make them beneficial for the pharmacies to participate because otherwise there's no reason for them to participate. So the goal is that the fee structure for pharmacies is better than what they would otherwise receive. But I think that some independent pharmacies and others just don't find that to be ideal or they look at the savings that are available and they want a larger share and it's hard for me really to speak from that perspective, but those are the sorts of objections that have been raised is that pharmacies may just choose not to participate or feel like this is forcing them to participate against their will. And Nate, what's the process that SafeNetRX uses to verify the integrity of a drug? You know, I actually don't know the answer to that question. If Nancy Hogue is on, she may, I think she was involved in evaluating the SafeNetRX program several years ago, but I was not. So I don't have a great insight into what that looks like. I do know that we see in our pharmacies at EVM huge, huge, huge volumes of drugs that may or may not otherwise be saleable and useful and uncontaminated and adulterated get returned to our med safes. We have these essentially receptacles in front of each of our pharmacies where people can return medication of any type that they don't want to use. And we really encourage people to do that because having unused medication hanging around is very risky, but the volume of return drug is just enormous. So we know that what's true nationally is certainly true in Vermont, that there is a huge amount of unused drugs going to waste. It's a fascinating topic. You know, it's one that's been brought up so many times in the past. And I remember approximately 20 years ago, a representative coming in, making a pitch for a bill that would basically recycle unused drugs. And as an example, he brought in pictures of over $10,000 worth of cancer drugs that were in his refrigerator for his deceased wife. And you look at it and you think it's so wasteful, but then again, you have to protect the integrity of what the patient is getting to. So it seems so logical, but it seems so difficult to implement. And maybe with this SafeNetRX, some of those hurdles have been overcome. Yeah, I think they must have come up with a process for how to review medications for appropriate reuse. I'm sure there's criteria about what it looks like and how it's been used and how it's been stored and what type of drug it is. But it's certainly the case. I mean, compared to 20 years ago, the cost of drugs is just astronomically higher. So it's routine now for us to send a single shipment of drugs to a single patient that's over $100,000 or over $200,000. So it's just, it's more urgent now. It's been forwarded since then. So that's just a matter about today. Right. Yeah. Okay, questions from the board for Nate? I have a couple. Go ahead, Tom. The first is I think it was back on slide eight. You don't need to go there, but there was a reference on option 2B having to do with reforms or changes in the HVP program. And there it is. And the very last phrase in parentheses says, funding sources for state dollars could include fees paid by drug manufacturers. And I'm wondering if you folks, my guess is that you didn't, but if it would be worthwhile kind of mapping out for someone to map out all the points of intersection between drug sellers and drug manufacturers in the state's application of fees and taxes, just so that there's a complete context of that. So that that might help inform options and funding levels associated with options. I agree. You're correct. That we did not do that, but I do agree that I think that would be useful. As we were talking about this option, we knew that there were current fees coming in from drug manufacturers, that those fees were being used in different ways. We also understand that part of the problem here is driven by drug cost inflation from an industry that tends to make higher and higher profit margins every year. So part of the solution that we could extend to vulnerable patient populations in Vermont may be usefully funded by the industry that's primarily benefiting from these high costs. Yeah. So when you say fees, what is the entity, the state entity now that assesses and collects those fees on drug manufacturers? Is it the tax department? No. I can jump in if you want, Nate. Yes, please. Thank you. No, Tom, it's not the tax department. It's AHS that assesses the manufacturer's fees on drug manufacturers. That was done a few years ago and used to fund various things, as Nate said. So those drug manufacturers are both in state and out of state? They're drug manufacturers who Medicaid buys drugs from because there needs to be a nexus with the state. Okay, because I was just wondering if, I mean, a reform that was made back in 2004 at the tax department was transitioning from a tax if an entity had property in Vermont to a tax based on the amount of sales in Vermont, the property in Vermont, and there was a third category. Called Unitary Combined, and I'm just wondering if taking a look, I mean, there's a lot of money flowing through people's hands here and taking a look at those flows and where the state intersects with them, I think might be helpful to helping folks decide which path to take. And the other question I had is, does the work that you've produced here, do you have any sense of its alignment with the work in the same area that's going on with our federal debt delegations? I mean, there's a lot of talk about high drug costs and I'm just wondering what the compatibility, what your thoughts are about compatibility between these recommendations and what you know of the paths that our federal delegation is following. I know something about it. I'm sure there are others that will know more. I think that we tried to stay away from the types of reform efforts that are happening at the federal level or are being discussed. I think that there's some narrow opportunity for Vermont to make progress in this area without coming into conflict with some of those federal reform efforts and without running into issues about supremacy, et cetera. So we stayed with pretty local provisions and I think from that perspective, it's not incompatible with anything. I'm aware of this happening at the federal level, talking about changing rebates, about shifting approval processes. Those are significant reform efforts that the federal government and Congress are considering that I don't think would present any conflict with any of the proposals that we've made here. Well, thank you. This is a very nice piece of work and it's kind of broad in its scope and I thank you for doing this. And I asked all my questions at the prescription drug tag meeting. So I don't have any further questions, but just wanted to thank Nate and the subgroup in its entirety for all their hard work and pulling together options as well as the other members of the tag who are busily working on PBM issues. Thanks, Robin. And do you have a timetable for when you think they might be able to present? We did check in with them. Christina can correct me if I'm wrong, but they are still currently hearing from national experts on different issues. So they think it's gonna take them a little while longer to come up with their options for presentation. So I wouldn't be surprised if that takes a few more months. Okay. It just was so clear and review the savings that Blue Cross was able to achieve by moving from express scripts to Optum that there's some big money that's being made by the middlemen. And it's an area that certainly is one that the state really needs to explore. So at this point in time, I'm going to open it up for public comment and questions and any member of the public can either use the Teams function to raise their hand or just speak up. So members of the public, public comment. Well, this is quite unusual. I don't know if it's because it's not a Wednesday afternoon meeting and it's a Friday morning meeting and we don't have as many members of the public or what, but I don't see any hands raised. I see a flashing blue on the phone number that starts with 1-410-804. Okay. I don't even see a flashing blue, but if they wish to speak, they're free to do so. It is flashing now. But apparently they do not wish to speak. So with that, Nate, Christina, Robin, I really want to thank you for all the hours and hours of hard work you've put into this. And Nate, you've come up with some interesting options and the real goal is to present these options to the legislature. That was the goal from the beginning to try to create a different set of options that would be available and continue the process so that Vermonters can weigh in and we can hear from different members of the industry to see what works and what doesn't work. And Christina, is it possible for you to set up an open public comment period on this presentation on our website? Yes, I will do that today. Super. So, Nate, thank you very much. Christina, thank you. Robin, thank you. Is there any old business to come before the board? Is there any new business to come before the board? If not, I hope everyone has a great weekend. Unfortunately, the weather's not going to be too pleasing. So if you get a chance later today, get out and see some of those leaves because they're probably going to be off the trees by the end of the weekend. Bye, everyone. Wait, we need to adjourn, Kevin. We need to adjourn. I'm going to adjourn. Is there a motion? So moved. Robin, move to adjourn. Tom. So moved. Second. Thank you. I wasn't thinking for signify by saying aye. Aye. Aye. Any opposed? Thank you, everyone. Bye-bye.