 I think we can get started. Again, for those of you that just joined, my name's Elizabeth Sutherland. I am a managing director in the health and life sciences practice, working with Oliver Wyman as a contractor that is working with the Green Mountain Care Board in collaboration with the agency of Human Services to hear from Vermonters about their, experience accessing and receiving healthcare across the state. Our goals, I'll get into those more deeply in a moment, but the intention of today is really a listening session to gather personal experiences and hear from those who are, we're leading both community and provider sessions so that we're getting the input from those who are providing healthcare and those who are receiving it to understand where are their barriers to care, where are some of their bright spots. And you'll note that we're hoping, but the goal of recording here is to just be able to make sure we're not missing anything. We'll delete and destroy all of the recordings afterwards. We just wanna make sure that we hear you and will not attribute anything specifically to anyone. We'll combine everything together so that it comes together as kind of a summarized view of the community experience. Why don't we move to the next slide, Gretchen? And so for a little bit of overview, just gonna talk to you about Act 167 here. Sorry if this is a repeat for folks that have joined some of these before or know this, but just wanna make sure we're on the same page. Act 167 of 2022 has a requirement for the Green Mountain Care Board working with AHS to develop and conduct a data informed, informationally informed, so patient focus, not just math, but information informed from patient experiences, community inclusive engagement process to take information from those that are experiencing healthcare, either from the patient or the workforce side to help us reduce inefficiencies, lower costs to the patients, improve outcomes, reduce health inequities, and increase access to essential services. We're doing this through kind of a, there's four angles to this. The first thing is just kind of what we've designed these listening sessions to hear firsthand about experiencing navigating the healthcare system. Like I mentioned, we're doing this with the community. We're also doing with provider groups. And then we have also had some targeted groups to make sure that we're creating access for those who might not be able to join a Zoom call in the middle of the day or for other reasons, being on Zoom to hear their voices. Mentioned we're doing the community meetings and provider meetings. There will be multiple rounds. So this is the first round. The meetings that are taking place during this fall are being conducted virtually for us to get an initial perspective. We've got over a hundred meetings like these scheduled. And then in the spring, we'll share back kind of the synopsis summary of what we've heard from the community and providers and what that means in terms of some recommendations that we'll have for hospitals focused on local priorities, based on local priorities. Our work is particularly focused on hospitals within the state, but we know that healthcare is not delivered in a vacuum. And so anything that you can share that is a rant like outside of hospital care that contributes to your own healthcare is helpful for us to hear, be that transportation, access of hours, mental health, things that kind of that would fall maybe more in the social or policy side of things. We're here to hear those too. We go to the next slide, please. Just a quick flash of our team here. You've got myself, Elizabeth and Gretchel on the line today. I, as I mentioned, I'm a managing director in health and life sciences. I've got over 15 years working in kind of improving hospital operations to increase access and increase quality. Most recently over the last five-ish years, I helped build and run Oliver Wyman's health equity platform. I've worked with a couple of different states to implement executive orders from governors to address health equity across the state. I'm a systems engineer, so I try to look at things from all different moving pieces. While I was getting my master's in systems engineering, I spent some time in Burlington getting a certificate in food systems to try to help bring some more of the healthcare aspect together. So very interested in all the moving pieces that you guys have to share. I'm joined by Gretchel here, a consultant from Oliver Wyman, who is going to help us stay on track today and she's capturing all of your notes. And then we'll make sure that we get those summarized together for our next round. Gretchel, can you move us forward please? All right, so today's goals, I'm gonna give probably five more minutes, not quite 25 minutes, but five more minutes of just some overview of some of the healthcare landscape trends that have really driven the need for this, for Act 167 in case that's kind of insights from the folks on the line here to tell us about your experiences. And then we really wanna spend the majority of this time hearing listening from you. We've got some questions that we'll put up as prompts but you can feel free to go outside of the lanes of the prompts as well. And then we'll just wrap up with a couple closing remarks. It's okay Gretchel, thanks. With a couple closing remarks and provide contact information if you wanna share anything following this discussion. Alrighty. So just a couple of stats, like I mentioned, we've got one of the things that's interesting particularly about Vermont is that while Vermont has a lower uninsured rate as compared to the nation, national uninsured rate is around 8.5%, Vermont's is around 3%, it has quite a bit higher of an underinsured rate. What we mean by underinsured is those that have health insurance but are still making decisions to not receive healthcare or making less than optimal decisions for their healthcare based on cost. And so we're trying to really get under what is where those issues are kind of stemming from and how we can make healthcare more accessible. Slide. This is probably known by all of you. We're all feeling it in terms of the annual premiums. What you see on the left here is just the annual premiums have been going up for plans and as well as the maximum out of pocket. So if you've been able to keep your premiums lower with your silver plan, then your out of pocket spend is going up. If you've been able to keep your out of pocket spend down when your platinum plans, your premium is going up. So we understand costs are going up, it's hitting everyone and it's not sustainable. And so this is another reason why we're trying to deconstruct today's healthcare system within Vermont. Next slide, please. Last slide of just kind of some stats here. Another area that we're looking into is access. And so what you see here is wait time for specialist appointment. People are waiting up to 90 days for some specialists and I know I've heard more, I've heard six months, I've heard outside of that for particularly around psychiatry and neurology. And so I know that these things, it's not, there's no way that we can be taken care of ourselves when we have to be waiting. And it's harder to book a appointment with your physician that you need to and it is to go on a vacation or to book very other complex things. And so our goal is to be decreasing this as well by increasing access to these specialists in addition to healthcare and tertiary care. All right, so we're almost to the listening session. Just wanna give a couple of house rules and overview. Like I said, we wanna hear directly from you. Next page has a couple of questions and prompts that you can reference. Bless you. The information gleaned will be used to inform options, like we said, for both short, medium, and long-term solutions to help keep things sustainable. I'll get to you in a minute, Patrick, thank you. If you need support now, they're just wanted to highlight the healthcare advocate information here. If you're not aware of that already to make phone calls and kind of either about specific issues of today or things that you're hearing on the line here. Couple of things around house rules. Try to stay on mute if you're not speaking. We wanna make sure everyone has the opportunity to speak and share in an inclusive way. We wanna use the raise hand feature and we'll call on you in the order of the hand being raised. I'm just gonna give a quick overview of that. If you see at the bottom or somewhere on your screen that says reactions with a little smiley face, if you click on that, there should be an option to raise hand. If that is annoying, can't find it, just either ping us in the chat or come on video or just come off mute and let us know that you'd like to say something and we'll get you in the queue. We're gonna try to keep, we'd ask you to keep your time to three minutes. We will not cut you off. We wanna make sure we're hearing everything that everyone wants to say, but again, to try to give everyone an opportunity to speak, we're trying to keep it at around three minutes per person and then we'll be monitoring the chat as well. So if you wanna throw comments or questions in there, feel free. Patrick, see your hand up. There, can you hear me all right? Yep, I can hear you. Thanks, my name is Patrick Fudd. I live in Woodbury, Vermont. I think I can keep this three minutes. I'll do my darnedest. First of all, I wanna thank the Green Mountain Care Board for its leadership in setting up these meetings. This is phenomenal how many meetings you're setting up and I think it's really great that everyone's taking time to listen to the public. We all know the problem, but I don't need to reiterate them here. You highlighted a couple of really important ones. People just can't afford health insurance and so they can't get it and it's becoming a crisis for a lot of remonters. Usually when you have something this complicated, there's never a silver bullet. There's never an easy answer, but you know what? I think in this case, there actually is a silver bullet. Back in 2022, Mathematica did a report for the Green Mountain Care Board on hospital sustainability. And two of their findings were that there was an awful lot of avoidable care in Vermont hospitals. That 10 to 34% of inpatient care in Vermont hospitals was considered avoidable. And 25 to 40% of ER services in Vermont hospitals was considered avoidable. That means basically, if people had gotten proper care ahead of time, they wouldn't have gone to the hospital. If they could get proper care outside the hospital, they could get out sooner. That's a huge amount of money. If you do the math on our total hospital budget, that is a huge amount of money that's basically being wasted. It's being spent in hospitals when we don't need it there. What we do need is that money basically transferred to the community services. They actually help keep people healthy and out of the hospital, primary care, mental health, home health, other community services that are designed and intended to keep people healthy and out of the hospital. And those services are being starved. While we're spending all of our money on our hospitals, we don't need to go into the rates. The rates continue to escalate year after year. We're putting the money in the wrong place. Europe has had a different approach to all of this for many, many years. They fund prevention, they fund community services and they get better outcomes at a much lower cost. I have no comprehension as to why this country can't do that or at least this state cannot take a look at that model, take a look at the avoidable care numbers and realize we have to do something drastically different. I will add though that we also need to restructure our hospital system. We have a hospital system that we actually don't need. That's why there's so many empty beds from time to time but we also can't afford it. And we have to take the time to restructure our hospital system to make the best use of our hospital infrastructure. And I don't think a single hospital has to close. I don't think people have to lose their jobs. I think it's just redesigning. And you said yourself that you were a systems engineer. And so you get this. We need to restructure what we have to make better use of it. And we will be able to afford the healthcare that people today cannot healthcare. And I'll just wrap up by saying honestly, if we don't, if we don't change the status quo, if we don't challenge the vested interests, we're just gonna be here next year and the year after having the same conversation and the same problems. And I thank you. Thank you, Patrick. I think you're definitely preaching to the choir here. I agree with everything you're saying. Thank you for sharing that. I believe we had Alyssa next and then Kelly. Yes, I'm here. So I have to apologize first. I was only able to jump in at the very end of your slides and I don't know if you address the issue that I wanna talk about a little bit, which is physicians leaving the CVMC UVM network. And I've had that, my interest comes because I'm in the Southbury Clinic with a general practitioner for many years. It was wonderful and she's just told me she's leaving. And I'm aware through talking to her and losing another specialist within the last few months that there's burnout going on within the system and there's a cascade of physicians leaving. That left my practitioner having to cover and work late nights. And now she's leaving, which was my greatest worry. I have five and six months referrals on other specialists within the network and this is just not functioning. So I wanted to raise that concern and I'm wondering what the Green Mountain Care Board, what kind of oversight you have on the income and well, profits, how that's being spent because it feels like from reading articles and awareness that there's a lot of traveling physicians being brought in to cover for these departures and traveling nurses, they charge way more than keeping existing physicians there and something is upside down where the system is not spending money to keep these incredible practitioners here within the network and is spending a fortune in an emergency to bring other people in or just remaining understaffed and then burning out more physicians and more nurses who are leaving. That's my perspective. And so what oversight do you have in terms of an insight in terms of where the money is being spent and what are you doing to address this issue? Yeah, thank you. Just to can't answer totally about what we're doing to address it yet other than the workforce and talent pipeline is part of our recommendation space. So looking to, and that's not that's physicians, that's nurses, that's also the supporting staff so that we can get folks to top of license because right now I think that to your point that burnout is coming from doing tasks that are not what, in addition to seeing a huge patient load than also doing things that are not kind of what the job is really meant to be for those that have clinical degrees. And so here you appreciate it. If you have any information about why folks are leaving like the specific reasons that they decided to leave that would be helpful for us to gather as well. You're asking me to send that an email or discuss that here? You can or you can share it now whenever you're more comfortable but it's helpful for us to like be able to cite people have left because of X. So whatever your comment is. I mean, I asked my doctor if I permission to speak at the forum and she may be listening. My impression, I happened to see her several times of the summer because I was having a health need that required frequent meetings and I could see in those meetings her increasing stress and her talking about her late nights and the overwhelming schedule. One of the issues that came up was her feeling that under the new administration or rules there was gonna be, I think this is not arrived yet but will be shortly forthcoming and forgive me this is secondhand but that there will be further constraints on physicians having autonomy in the scheduling of their patients and more pressure to see them in much shorter like 15 minute time frames. My doctor explicitly was saying that that seems irresponsible in light that people travel so far from rural settings to come for an appointments and to see them that one, the reason she got into healthcare was to engage with patients in the time that they need and that she feels she was losing and was gonna lose more control over her schedule. So she is moving to a private hospital outside the network. The other reason was burnout because she was having to cover for other physicians and stay up late late at night working at the hospital at times, covering. And I think those were the two major issues a lack of autonomy over her own schedule and a sense of burnout. Another factor is that I gather she was eligible for tuition reimbursement through a program that existed before COVID that was then suspended and when applied again stating to me that she was qualified did not receive that. And that seems like that's a bait and switch to practitioners to offer to bring them into the network through a tuition abatement program cease it during COVID started again and not follow through with those commitments. I think, I mean, I can't speak to what any one of these things what was the most major factor but I think you start losing confidence in an administration when things happen. The other thing was turnover within the leadership. I don't know the details except that I gather a vice president again is leaving and there's been a lot of turnover at the top at the hospital. And so, yeah, it doesn't seem like a very welcoming environment and I gather that recruitment is not going well and I'm left as a patient without knowing who my practitioner is gonna be. I'm told that I'm gonna be in the practice but might see a visiting physician might see random people in the practice I've in the midst of a health issue and I have just I'm about to lose my continuity of care and this really concerns me and I'm sure it's happening to other people given the numbers of physicians leaving. So, yeah, this is a big problem and it feels like the money is being spent in the wrong place. We're not supporting our primary care physicians. We're not supporting the people on the ground and keeping them here and it's hard enough to recruit in rural Vermont. So why is the administration making it harder? Yeah, thank you so much, Alyssa. I appreciate all of that. All right, I've got Kelly, Melinda, Paul, Hope, Brian will go in that order and then Ken, I see your hand there. Okay, adding you. Okay. Yeah, hi, this is Kelly Driscoll Smith. I just wanted to talk about based on your questions on the screen there about some recent experiences. I feel like there's a big disconnect between the hospital or providers and insurance companies, especially when there are medical authorizations that need to take place. And I'll just give you an example. I recently went to my primary in August. She referred me for a CAT scan, lung scan and that was supposed to go up to the radiology department at CVMC and I've called them at least four times for follow-ups and just barely got my appointment. And now I can't get the appointment until the beginning of next year. And now I hit up against my new deductible. So I think there's a big disconnect between the medical authorization departments for the insurance companies and the providers and they're not following up to be able to get timely care. And a lot of people are trying to depend on getting care before the end of the year because they've already met their deductibles. And okay, now we have to start all over again because you're not able to get in timely. And like I said, this started in the end of August. So there's no reason that I should not have been able to get that appointment scheduled before the end of the year. And now it's in January. So that's one situation that has just recently taken place. The second situation actually just occurred yesterday and it happened with my husband. He gets most of his care down at Dartmouth. However, he was experiencing some issues and Dartmouth wanted him to have lab work. And so he went to CVMC to have the lab work on Monday and CVMC was supposed to send the results to Dartmouth. And they didn't get them until, I mean, the results showed up in the portal like within three or four hours. So my husband knew what the results were. However, the doctors at Dartmouth didn't receive them until yesterday at noon-ish. So there was a big disconnect in that situation too where this is kind of a serious, my husband's amputee and he's had infections after infections and the lab results were pretty significant when it comes to him needing care pretty quickly. So those were a couple of experiences. I've also had some billing experiences with CVMC where they're billing things that need to be corrected. And it's three months later and they're still not corrected. So just some of my experiences and I kind of think that's what you wanted to hear. So that's what I have for you for now. Thank you for sharing, Kelly. Melinda. Hi, my name is Melinda Schmaltz. I am a teacher. I have a complex medical history that's been going on for over 10 years. One of the things that's come up recently is that I have medical necessity to have compression garments on my arm or else I end up in the hospital with infections, which has happened. I'm prescribed three sets of compression garments. I'm supposed to get them replaced four times a year which cost me $6,000 a year because they're not covered by insurance 100%. So I can't afford this $6,000 out of pocket. So I end up getting less of the garments than I should have and I get them replaced fewer times than I should which also means my arm is more prone to infection. It's inconsistent. And I think that anything that is medically necessary that isn't covered 100%, you know, they don't cover it but then I end up in the emergency room and that's far more than if they would have just covered the garments that I need. The other thing is my doctors and specialists are all out of Boston because they don't have the quality of care in Vermont and when I go to get these garments made there isn't anyone in the state of Vermont that makes custom garments. And recently the last set of garments I had took me months to get approved because I was told that any vendor outside of the state of Vermont would be denied. So it's just, it's not helpful. It's not following what is medically necessary and it ends up being unhealthy to not be able to follow what is prescribed by my doctors. And I just think there's a huge problem. I should not be paying and this is just one incident of my healthcare. I should not be having to pay $6,000 a year to follow my doctor's recommendations. It's not good for my health and it's eventually, you know, when I end up in the emergency room it's not good for the insurance either. That's all. Thank you for sharing Melinda. Paul, oh, you're on mute, Paul. Oh, we still can't hear you, Paul, I'm sorry. Sure, yeah, we'll give you a sec. How about now? Great. Okay, sorry about that. Technological problems with Zoom. So I'm a nurse and I also work in public health and I was excited to hear that you're a systems analyst because if we actually get a healthcare system in Vermont you'll have something to analyze. But right now our system is woefully fragmented and I have a recent experience that really illustrates that my mom's 91 years old. She's currently living out of state but we had the exciting opportunity to move her here to a new memory care unit that's been developed in Montpelier and was very excited about the opportunity. Here's some new capacity coming into our local healthcare system. And one of their requirements for her being admitted was that she have a primary care provider within two weeks of being admitted to the facility. So I called every primary care practice within 50 miles of Montpelier including all of the CVMC practices and remarkably discovered that the one with the shortest weight could put me on a weight list that was 12 months long. Many of the other practices wouldn't put me even on a weight list because they said the weight list was so long that there was no chance that I would ever get to the front of the list. So the lack of primary care capacity in the community is just stunning. I would challenge anyone to make calls and try to get a primary care provider in central Vermont in any time within a year's timeframe. And then ultimately what had to happen is my own provider who is overworked and swamped agreed to see my mom out of the goodness of his heart but of course this is what contributes to burnout, right? So now you have a guy who's going to be working over time to see one more patient in order to make our system sort of function. I mean, it's just a great example of the disconnect between here we're adding new capacity in a much needed area. We know we have an aging population. We know a memory care unit is something that's badly needed in Vermont but you can't actually get admitted to it because we don't have the primary care providers to support that. And then as Patrick Flood stated people end up in the hospital with problems that could have been prevented or dealt with at a much lower level of care. So that's my experience just in the last week and it was eye-opening in terms of just the inability to get primary care in our community. Thank you. Thank you for sharing. Mary, I'll add you. I see you. Thank you, Mary Alice. We are at Hope. Hi, my name's Hope Griffo and my comments are a bit more directed to possibly things that could change without changing the whole political structure which may need to be changed. And that is... The current system now has vaccinations being given in pharmacies as opposed to primarily in hospitals. While some hospitals, Dartmouth-Hitchcock for example does have a vaccination service right in the lobby and that would be, I think, very useful to a number of people to walk in vaccines for flu or for COVID, et cetera. My other suggestion would be to have dental clinics in hospitals or affiliated with hospitals in schools so that people, children could access some basic dental care and not have to go to the emergency room when they have a toothache. And then my final suggestion would be if there was a way to standardize forms so that one wasn't doing the same form for every kind of service provider they go to, that would be easier on the patient. Well, my last comment is that the translation services at the hospitals and the hospital-related clinics, that's a huge service and it is much appreciated. Thank you, Hope. All right, Brian. Yes, hi, thank you. First of all, I'm wondering if I don't know Green Mountain Care Board has authorized you to do this, but I'm curious about what the governor's role is. Has the governor endorsed this idea? Where is he in the behind the curtains, if he is? That is a great question. I don't know why. I don't know the answer to that specifically, but I know that this is a shared legislative goal across. Vermont's leadership. Okay, I hope I hope he is. Let me put it that way. My experience in the, well, first of all, I think that the whole healthcare system, and I speak here from Burlington having used both the ER and the hospital itself is bloated. I think we've got too much above and not enough below. I'm working with, I'm a patient family advisor, both at the hospital and with one care. And I'm working right now with an NPG group which is nurse professional governance and also with a group called Pathways. These are both nurse oriented. They're generated at the nurse level. And I've been extremely impressed at the care that the nurses have given to their own practices and hoping to improve the patient experience in the hospital. That's a positive. Another positive is my chart. I have had such good luck, for example, today due to a scheduling problem that I had with a specialist, I showed up at the hospital and was told that my appointment was an hour earlier. So I jumped on white care with that specialist and within five minutes I had a new appointment. Granted it was in January, but that's fine because it's not an emergency. So the my chart for me and my personal, my PCP has been just great. My PCP is not part of the network, but he is connected to it. And he has also one of those that on his answering machine, I mean, when you call and get the answering machine, he specifically says we're not taking any new patients. He has added two PAs to his, or NPs to his practice over there. So he's enlarged it that way and is succeeding at doing that in my opinion. Let's see, oh, I was just at Central Toronto this afternoon and I had the opportunity to talk to an LNA and one of the practice speaking of deploying of the appreciation and the nursing and health professional staffs, this is an LNA who is taking a course to become an RN at Central Vermont. And I think that that's a real accomplishment over there. Certainly it was for her and she was very proud of it. I also was on the Central Vermont Home Health Board before moving to Burlington. And now I've just finished the term on the Home Health Board over here. So I see the real value, which is not being utilized to the fullest extent, I think in the Chittenden County area, Chittenden County Grand Isle Catchment Area for the Home Health Offices here in Chittenden County. Other than that, and the fact that I think the whole system is way out of whack in terms of balance between small hospitals and the mothership here in Burlington, it's all out of whack and I don't know whether you people can figure out a way to whack it back into shape, but I wish you luck. Thank you, Brian. All right, Ken, are you still with us? Yes, can you hear me? Yes, we can. Great. First of all, it's good to see a number of old friends of this part of this discussion. And I do think that it's worthy that the Green Mountain Care Board in many ways has mandated this conversation. I guess one of the opening comments that I have is that one might think this kind of conversation would be going on on a regular basis over the last five or 10 years where there's ample opportunity to get feedback, particularly from people who are receiving services. I'm not sure that's really built into our system. And I think notes should be taken of that. By way of quick background, for a number of decades, probably three or four, not years, but decades, I've been a mental health advocate here in Vermont. So I'm gonna limit a few comments to concerns about mental health and simply say that the mental health system has been in crisis for several decades. And it's become kind of a common theme. And most of the, a great deal of effort has been put into rhetoric, but not into services and programs. I think one of the great failures here in central Vermont was when was CVMC which is really, as people know, ruled by the UVM Medical Center, reneged on a commitment to add 25 inpatient psychiatric beds at Central Vermont Hospital. I was there numerous times over a long period when representatives of Central Vermont and of UVM testified before the Green Mountain Care Board saying this was an absolute critical need in our healthcare system. And as people may know, just a year ago after Central Vermont spent about $3 million doing planning, it was announced that the whole project was being eliminated under the guise that there weren't funds to run this program. And frankly, there's some truth to the fact that inpatient psychiatric mental health does not pay as well as some other areas, yet it's one of the great needs we have in our state. Really, the issue that needs to be addressed is that the more things get talked about, the less happens. There is not 25 inpatient psychiatric beds added or will be added in Central Vermont. I would guess for at least five or 10 or 15 years which is an outrage. And as people may know or should know, and certainly the Green Mountain Care Board knows, what often happens here in Central Vermont and it happens around the state is that folks who come in to the hospital, young and old and middle-aged, in need of an inpatient psychiatric bed often end up in the ER rooms of our hospitals, including Central Vermont. And that is really a travesty and it reflects poorly on the priority that mental health doesn't have in our system. If this was an issue of cancer or it was an issue of heart conditions, people wouldn't be spending days and weeks. And I've had contact, I've retired now for 13, almost 14 years. I still have contact with parents who call and say, my daughter's been in the ER for 10 days or 12 days, which is a very bad environment. And it really is unfair not only to the patient and the family, but it's unfair for the practitioners. So really the question that I would have or is what are we gonna do about expanding inpatient psychiatric beds? It doesn't solve all the problems in the mental health system, but to continue to have people wasting away in emergency rooms in our hospitals is just a almost a malpractice. And I think that that issue has to come back up. I know the state has tried to initiate some initiatives that might be what I would call slightly helpful, but it doesn't replace the need for inpatient beds here in central Vermont, which seemingly was a five year period of planning. So that's the focus that I'd like to leave you with. Thanks. Thank you, Ken. And definitely something that we're looking into kind of on the same side of avoidable care. There are things that are happening within the health, the thought in the hospitals that need to be revamped so that we can prove providing access to folks either earlier or in a different way. Thank you so much. I've got Rob, then Mary Alice, then John, then Lila. So Rob, you're up, thank you. Good afternoon. My name's Rob Hoffman. I'm a volunteer with the Central Vermont Refugee Action Network. And so I'll just comment briefly about trying to get care for some of these folks that come to our state, to our country and to our state with virtually nothing. Some of the children are covered under the Immigrant Health Insurance Plan, so Medicaid-esque plan that the legislature established. And just like everybody else is noted on the call, getting access is certainly difficult, and all the things you covered in the slide at the get-go were very un-message and accurate. But once you can get by some of these hurdles and roadblocks and barbed wire to get people actually into half-care, I just wanna comment on a positive in this whole thing is how wonderful some of the providers have been to these folks who don't speak English, their cases can be difficult, and the providers have been absolutely fabulous. And probably the biggest trouble is with dental, and that mirrors the problems that we have is just patients in the state, but many, many, many doors are slammed in our face because providers, dental providers, won't accept Medicaid, and they indicate that they can't do any additional billing to make up for their desired rate and the reimbursement rate, so they don't participate at all. Few people have, and I just wanna quickly note the Waterborne Medical, LaMoyle Health Dental Clinic, People's Health and Wellness in Barrie, and lastly, Timber Lane in South Burlington, and it's been inspiring to see how loving and caring the front desk, the nurses, the dentists, and doctors have been to these patients. So I just wanna comment on that. And then lastly to note, I served in state government for years with many of the fine people on this call, starting as finance commissioner, ending as secretary of human services, and one of the absolute best people I served with was your first speaker. So I would encourage you to tap him and get the long play version of what Patrick Fudd can do to add to this conversation. And I know he's active in this arena, but he was absolutely one of the best people I worked with total common sense. And I echo his call to kind of shape things up because you don't wanna wait till things are teetering like they have been recently at the state college system where difficult decisions are deflected and deferred until they become unavoidable and much more difficult to fix things at that point. So I'll end there. Thank you for hosting this forum. Thank you, Rob. All right, Mary Alice, I'm sorry, couldn't read my own writing. Okay, can you hear me? Yes. Hi, I'm Mary Alice Bisbee, I'm 86 years old, live in subsidized housing in Montpelier. And I've been around for a while and I'm pretty much of an advocate for universal healthcare, single payer healthcare, nationally and statewide. It goes nowhere every year. And one of the big things which the gentleman before me mentioned, dental care for many years, the state of Vermont will not make dental care even part of healthcare, which seems to me ridiculous but anyhow, I wanna talk about the inequities in our healthcare system. If you have insurance or good insurance, you can get very good care. But if you don't, if all you have is Medicaid or maybe you don't even have that, you don't get much. I was in the ER the other day having had a bad reaction to a COVID shot and another shot of my other arm and I couldn't sleep or anything. And the doctor gave me two choices. He said, well, we can send you home and everything looks okay, but or we can take blood and we can give you a chest x-ray and do all these tests and everything. And I said, I want all those tests. I'm here. I have wonderful insurance. Of course I am paying $251.44 a month for UnitedHealthcare, which there's a big problem with UnitedHealthcare, which you probably all know in Vermont, but I have a plan J, which is grandfathered in. And I find there are many others of us who are my age or about who have been carrying this insurance. And the thing about that is there are no deductibles, no co-pays. Whether you go in the hospital or have to go to a nursing home for rehab care only, not for long-term care. But I just think it's ridiculous, the inequities in our system. A person who didn't have any insurance would walk out and they might have COVID, they might have whatever. And I don't think that's over-utilizing services. We just don't have enough. And every doctor and PA that I've talked to in the last few months or years even, they all say how horrible the system is. Everybody. And this value-based care is just going to make it even worse. And that's something that's coming out of the national. The doctors no longer have a say what they can do and what they can't do. They're told by the insurance companies. They're told by one care. And I just think we need to make some real big changes. All those administrative costs that are going on top of what people get for services. If it were only the doctors and the nurses, they wouldn't be leaving if they were able to practice the way they, they ought to be practicing where they would have some say in what is being done. It would be a very different system. And certainly we're the only system as Bernie will tell you around the country that just doesn't have any decent healthcare here in the whole country. But thank you to the Green Mountain Care Board for having this listening session. And I don't know if I've said anything, but I hope it's wonderful to hear all these other people what they've had to say. And I hope something will get done finally. The Green Mountain Care Board is to be thanked for this. Thank you. Thank you, Mary Alice. Appreciate everything you said. All right, John, sales. Oh, we can't hear you. Is that better? Yes. Okay, I put my thing up. Thanks for the opportunity. I have lived in Montpelier for 24 years and get my healthcare through CVMC and the primary care practice there. And, you know, I echo both the good and the bad of good and the challenges of what everyone else has said. A lot of what I have heard I have experienced. What I really wanted to make a quick comment to just zoom out to like 50,000 feet. And I hope that this process is going to address where the setting of overall healthcare policy lives in the state because right now, also I want to say I'm a former board member of One Care Vermont. So I spent a number of years on that board. It really feels like no one is in charge. My experience has been that the Green Mountain Care Board doesn't see itself as the organization that sets the healthcare vision. I think this administration has not seemed outwardly engaged in setting a long-term healthcare vision. And I think that my experience has been that the legislative process is ill-equipped to set a long-term healthcare vision. So I would just like that to be reflected in whatever analysis is done that without somebody putting forth a vision and a roadmap to get there that we're going to keep floundering and keep having challenges and keep doing half efforts to try and get to a place that isn't really defined. Thanks for the chance to talk. Important points. Thank you very much, John. All right, we've got Lila, Lila, and then Walter. Hold on, Walter, you're right after Lila. I was having trouble in muting, sorry. I do intend to submit written comments. So I'll try to be brief here. My first question, my first issue is a process question for Oliver Wyman. There is a lot of discussion on the website about the opportunity to submit written comments and there's a form, but I'm concerned that there's no real clear timeframe for submitting written comments. And I would hope that Oliver Wyman can indicate like how soon should comments be submitted in order to be incorporated in the process of reviewing community input. I know you're trying to synthesize what you've heard from a lot of different meetings. The meetings are basically ending and I'm assuming you're going to start doing that work. So I've encouraged a lot of people to submit written comments because I couldn't come to the meetings and I just would like some clarification on the timeframe. Thank you for both. Thank you for urging folks to do it and thank you for asking. We'll make this more clear. I think that what we would ask is that just within, before the end of November to get them in, we'll be working over December, January, February with Mathematica to do some kind of like some modeling of some of our recommendations but then we're also coming back in the spring. So if folks don't get things put in like it's not Speak Now or Forever folder piece, we're trying to, we'll still incorporate that input through March as well. And so I think we can put some language on the website to just say when we would like to have it submitted by but also it won't be just a, won't be totally turned off by the end of November. Right, okay. I assume that you would have ongoing comments but the end of November is coming up soon. So if- You're right, you're right. Thank you. And Thanksgiving is right in there too. One point that I wanted to make here is that I've been disturbed by some, what I would consider marketing of the Medicare Advantage Plan that University of Vermont Health Network has developed. We're in the period of choosing Medicare plans and open enrollment. There's a lot, a lot of material that everyone in Medicare is probably getting and EVM has this Medicare Advantage product I've gotten several letters which are return address from CVMC. And it seems as though CVMC and the network is using patient information. My name addresses and presumably the fact that I'm in Medicare to send me these letters. And they would argue that these are not marketing materials. I would say they are very strongly urging people to sign up for this particular Medicare Advantage Plan and I don't think it's appropriate. I think it's a conflict of interest for the healthcare provider to be healthcare insurer. So I hope that that's not a trend in the future. And I guess at this point, I would just close and let other people have time to speak. And as I said, I will submit more comments. Thank you. Thank you. All right, Walter, you're up and then we'll go to Jennifer. Walter, you're muted. I had turned the mute on, it went off again. I wanna echo some things that John and Ken had said earlier about this process. I've been in this process since 2009, right after Obama got elected and I'm a long, long-time single-payer healthcare activist. I work closely with the Green Mountain Care Board. I'm on their advisory committee and I almost died from private insurance in 2006, 2007. It was so close, the doctors didn't even think I would make it. And if I had lived in a system like Norway, Denmark, Pick One, nothing like that, I would never have come as close as I was. And so I have been to these meetings for many, many years. Every year we collect the data. I served on a prior authorization study committee too with the Care Board back in 2015. The results go to the legislature, they go to the appropriate committees, they're promptly put on the shelf, they collect dust and that's all that we see of them. Is that what's gonna happen to this? That's the question I have because we're gonna present it to the legislature, the health committee or whatever appropriate committee they designate for this. They'll say yeah, it's a great and wonderful thing and then just leadership will tell them to put it on the shelf and that's where it's gonna sit. We've been through this time and time and time again. I think it was John who said the legislature is not adequately prepared to work with something like this and I believe he's right. And I guess the question is, is how are we gonna move this forward? Yeah, I appreciate that Walter. I think where we've heard this and as consultants we also wanna make sure if we're coming in to do things that seem to have been done either the same or differently in the past how we can make sure that there's impact, increased impact. I believe that is the goal of the Green Mountain Care Board and EHS is to push this forward so that we have a more sustainable and implement recommended actions from you guys that we've consolidated so that we have a more sustainable healthcare system. Can't commit to much more than that but I know that we're working to make real impact from this. Well, you know, your idea of a system and our idea is two different things. We have Act 48 which created the Green Mountain Care Board which has been in the legislative dustbin since 20, since it passed in 2011. And we've tried to pass universal primary care. All of these systems would have done something to alleviate the problems you've heard about tonight and we'll keep hearing about in the next hour. And again, great thanks but nothing will get done. Appreciate that. I would recommend looking into the AHEAD model that is coming in the next couple of years from CMS which is to move a handful of states toward a global payment health system model. And that is something that's on the table of consideration. And so there is some movement at the federal level too that can give I think a little bit more momentum to some change within the state as well. The federal government is trying to privatize Medicare. They're trying to siphon it off into Medicare these inappropriately called or Wellian called Medicare Advantage programs that Lila spoke about earlier. They're trying to privatize it. They're not trying to single payer it. They're slipping out of way to Wall Street. So DCEs, contracting entities or reach whatever that you want to call it. So they're not going to be doing anything with it except shifting it to private enterprise. Hope that's not the case. But is there anything else you'd like to share, Walter? Nope. Thank you. Jennifer Roberts. Hi, thank you so much for this call. I really am very grateful to have been able to listen in and this really important and honestly terrifying conversation. I just wanted to quickly share my experience in the last couple of years with finding providers. I moved back to Vermont about two and a half years ago and I was on a waiting list for a primary care position for over a year. I called them at one point to see where I was on the list and they told me I was number 224. And thankfully for me, they brought on a new practitioner, a PA, so they cleared out a lot of that list. So I was incredibly grateful for that. If they hadn't, I would probably still be on the waiting list. I had seen a specialty provider at CVMC who was great. When I went from my follow up appointment this year, she had left and the doctor I saw this time lives in Florida. And I don't know how often she comes to Vermont, but it kind of felt like that a little bit. So that was very disappointing. And I have an appointment in a couple of weeks with a different specialty provider. And so I thought I would do a little research on the doctor that I, because he's new to me. And he's not even listed on the hospital's website. So that doesn't give me a lot of confidence. And it's really, it's scary, scary for all of us. So thank you again for the opportunity to hear from the public. I really appreciate being able to speak. Absolutely, thank you for sharing that, Jennifer. Rachel, are you trying to say something? No, okay, talking to someone else, sorry. Would anyone else like to offer personal experiences, issues related to receiving healthcare because of specific situations? We've talked a little bit about equity, but would be helpful to hear more about that or anything specific about what could be improved. I know we've talked about dental access, dental healthcare access, better primary care. Oh, okay. I think Jennifer's, their hand is still from before. I just want to make sure I'm not missing you. And meeting guest, I see a hand up, but I don't see your name. So if you wouldn't mind just coming on and sharing your perspective. Okay, my name is Rachel Desilets. Rachel. And I'm still organizing my thoughts, but I do have two things that I'd like to bring up. You know, no one can deny that the cost of increase in healthcare is going up, including your office, which I can appreciate, but what never gets mentioned that if you're on social security, our yearly colas don't even cover the increases, let alone, you know, help in so many other ways. So presently I'm spending 20% of my social security on healthcare, premiums. And that does not include dental and no prescriptions at all. So that's one thing. And the second thing, and I hope I can be articulate here, ever since meetings or people have been asking for the communities to express their experience around healthcare, I have always brought forward to these hearings, the cost of diabetic medications. And I know that Congress just passed this wonderful bill, but if you're type one, you will not have to pay more than $35 for your insulin, which is great. I'm glad they were able to do that. But what they didn't do, even after before this even went to the floor and said, you need something for type two as well, their prescriptions are just as high as insulin is. So wouldn't you or whoever was certainly advocating for assistance with this medication for reducing medication for diabetics? I wanted to make sure that they were just not talking for type one, but for type two. The only thing that went through is type one. And I have my own cynical way of looking at why that didn't happen, but I'll give you some facts that I was able to find. And that is five to 10% of all cases of diabetics are type one. 90 to 95% of all type two are type two. And yet the amount for both are the same. Now, why do you think they were able to pass type one and did not include type two? I just leave you with that sort of question because it's impacting a hell of a lot of people who cannot afford it anymore than those who have type one. And yet when they had an opportunity to advocate for both that never happened. So we're back, I'm tired. I come into this over and over like many of the people who are here and it's, I can't say that I'm frustrated. I'm angry. That's the emotion I would use. I don't want someone to say I understand my concern. It's not a concern. It's not a frustration. It's anger is what you hear from me. Anyway, that's all I have to say. Thank you. Thank you so much for sharing. I thank you. It's righteous anger. Appreciate that. Alyssa. Yeah. Hi. I just had a quick question. I realize I'd really like to be able to share a recording of this meeting with my neighbors. I think it's something important that other people be able to hear. And maybe you reference this, but will there be a recording accessible that can be shared? I don't think so. I'm not sure. Let me check on that. We've been recording them for our intake and then our kind of commitment was to erase them so that people felt more comfortable sharing in the space that they're in right now. And so I will have to get back to you on that. We'll take that as it to do. I'm sorry I can't answer that right now. The going in plan is to not do that, but I can hear where you're coming from. And I don't think we'll do it for this because I've already announced to folks that have shared things that we're not planning to take it more broadly. Okay. Are there, is there another way for neighbors to get information on what's coming from general summaries of what's coming out of the meetings? Because I feel like if you're asking for comments and there's an opportunity to encourage neighbors to submit written comments, it would be useful for them to have a general sense of what's concerns have already been raised and become engaged by having a sense of what this dialogue is like, which is very useful. I mean, and I thank you for the dialogue or at least the opportunity for us each to speak. But I think the goal is more community engagement and it would be inspiring if people had a window into this in some way. Yeah, that's a fair point. I mean, we'll be coming, we'll be summarizing but in a couple of months. And so I appreciate your point. There is a PowerPoint online, no, consultants, sorry, but there is an overview of like a little bit more of what we're going into that people could click to get more information about what the different topics are that we're talking about. But in terms of this, what we're hearing from folks, we haven't, we're not planning to summarize until it's kind of all one to not attribute personally things. We may think about it though, Alyssa, I'll take this back. And can you clarify, because maybe you announced this earlier and I missed it, but the comments, is it on the Green Mountain Care Board website where the comments can be submitted or is it on some website that you as a consultant control? It's on the Green Mountain Care Board website. There is a, this is the information, thank you, Gretchel, here. So if you want to... Do a screenshot, keep that up. Gretchel, can you drop it in the chat too, just so people can click it? Okay, so it's on the main website under the community meeting subset or is it where the form is? Cause I didn't see it, but maybe I just missed it. I think it's there. I thought it was on the same place where the communities are. Let me look in the chat. I was looking at things quickly before the meeting, so it wasn't on my radar. We will get it in the chat now. Oh, there we go. Thank you so much, Gretchel. So you can click there. That should be, it is the community list of the community meetings and then also where you can submit written comments. I'm sorry, I'm just a public comment form, I see. Okay, that's what we're looking for. Thank you. Yeah, thanks for asking. Oh, I lost you guys when I clipped on that link. Okay, hello. Yeah, I see Mike. Mike, you wanna jump in? Sure, I'll jump in. Good evening, everyone. I'm Mike Fisher, I'm the healthcare advocate, which is a position in an office defined in state statute to be a public advocate, a public watchdog on behalf of Vermonters, really with the broadest of mandates to improve people's access to care. I give that description with the net recognition that there's people on this call who I've worked with and who have worked with our office. Hello, Lila. For years and years, so I just wanna echo what I've heard other people say, it's good to see a lot of old friends. I guess I wanted to comment briefly about the frustration factor that I've heard here. And many of us know each other. We've been at this for a long time. It's frustrating as can be. I would join with you on that. It's really hard to envision change at this time. And as long as I've studied the legislative process and the public policy process, it's really impossible to know when the stars will align. Sometimes they do and miraculous things happen. And they never happen unless there's a public push. Public push, meetings like this, comments like we've heard tonight are always a part of it. And so while I share some of the, I think Walter said it really clearly, I don't know what's gonna happen as a result of this. I share that concern. I also know that this is a part of the process for when we really can change things. When the stars align, can't say they're gonna align this year. I think that there's, I know that there's a lot of really serious pressures on the legislature. Particularly around housing. But healthcare is in the challenges of our healthcare system and the areas where we're not meeting people's needs are just as glaring. So I'm not sure if that was at all comforting or anything. I guess I just wanted to join in the conversation and say, I really appreciate the voices that we've heard tonight. And I don't have another answer. We gotta keep at it. Would anyone else like to share or share again? Hi. Hi, my name's Jennifer. Also, I'm not through the Zoom. I'm only in through audio, but I would love to share the purpose of that. I joined tonight with one to hear and also just to share. Again, I have just frustrations with healthcare here in Vermont. I am a nurse here in Vermont currently, but I've had recent family members who have attempted to access healthcare and have not been successful in doing so. I have a sister who has been told that she might have cancer but she can't get in to see anybody until next year. And it's very angering, let alone frustrating to be a nurse in healthcare and have a family member who is told, you might have cancer. We're not sure. We've got to get some tests, but we can't get in to get those tests because there isn't anybody to call in the referral to get you scheduled, but then when they do, we'll let you know then they call. And this for her all started in August of this year. And she's finally got her first test this week, but this entire time between August and today, she doesn't know, am I gonna be here next year? Am I gonna be here tomorrow? Don't know if I have cancer, don't know what's going on. That's one of the biggest frustrations. And I know just to, it breaks my heart, being a healthcare worker and I can't give her answers, I can't help her because I can't even get through to get anybody. We have a primary care person who we love, but they're also leaving. The one prior left as well. When you call to get an appointment, you can't get an appointment. Sometimes you don't even get a person. Sometimes it's a call center in another state who's doing the calling or the scheduling for the doctor here that we can't get in to see. And it's just, it's frustrating. A week ago I was very angry. Today I'm just frustrated. I've had some time to sit and think about it. But I also have other issues with my own personal children who can't get in to see their primary care for just an annual well child check. And they've been a patient for four or five years. They're not sick. They just need an annual well check. Insurance likes to have that done and we go in, we get the appointment after visit summary says, you know, see in a year unless something comes up and need to be seen, go to the front desk. We're not scheduling that far out. Call us in July, I call in July. Oh, we don't have anything available until 2024 now. It's just frustrating the access to the care itself can't seem to get anywhere. With anybody, anything. It's just frustrating. I've listened to what a lot of folks have said tonight and I agree. You know, a lot of them have the same thoughts, input that I am feeling. I feel our healthcare system in Vermont is broken. I feel that it is bloated. I think we are too top heavy when it comes to inside the hospital, as well as in our primary care offices, they're not allowed to do what they need to do to take care of their patients. They're being told, I'm being told this from fellows that I work with practitioners, et cetera, you know, that they're not allowed to order tests, just a standard test for a patient because it costs too much, but it's a test that could be life-saving and has proven with some folks to be life-saving. In my sister's case, it was this test that was ordered that had come back and there was something abnormal. So the doctor wanted to go a little further with it and she's gone further with it, but getting a lot of flack and for doing so. And so it's just frustrating, you know, and not knowing the last gentleman that just spoke, I think it was Mike, you know, we don't really know when there's gonna be an answer. I wish we did. I wish this call you could say, we're gonna have something, some changes. We'll see them, you know, next week or in six months or have some date to look forward to. And then I'll just close it with, at this point, my family, we're seeking care outside of the state because we seem to be getting quicker answers. This is my immediate family. We're going now to Dartmouth and further if necessary because we're able to get appointments quicker. It is a drive for us. So it does, you know, put a little bit of a hardship, just the transportation, getting there. Now we're heading into winter roads, et cetera like that, but that's just what I wanted to share. Thank you. My husband has a question. Can you have a moment? Okay, I think we've had Daniel's hand up and then can we go come back to you, Alyssa? Thank you. And then Rob, go ahead, Daniel. Oh, you're on mute, Daniel. Well, you think I figure that out by now, the whole of the Zoom. I missed the beginning of the meeting, but I just wanted to check, is this also a form for talking about the mental health care system here in the state? Yep. Well, my name is obviously Dan Tull. I am first and foremost a mental health and homeless advocate, but I'm also president of an advisory firm that's focused on processing system improvement in both mental health and the homelessness arena. And there are two interrelated points I wanted to make. I am a person with lived mental health experience, a psychiatric survivor. I've been hospitalized a number of several times, except for my hospital, the inpatient psych unit. And first of all, I just wanted to make a comment about the importance from mine and my fellow peer, mental health peer perspective about investing in community mental health supports, not psychiatric beds and other in a carcerative options, not only for the effectiveness and the diminished amount of trauma that is visited upon those of us who go through that part of the system, but also it can be extremely much more cost effective and in investing community sports that also includes preventative measures, which is obviously a system wide issue is how do we prevent people from getting sick, whether it's mental health issues or physical health issues. So that's the first point is as someone who's endured inpatient psychiatry in particular, and also was endured staying overnight in the emergency department, which is honestly in my 65 years, one of the worst experiences of my life. Having to be in the TCA unit and the ED at CVMC. The second point I want to make related to that is I want to really encourage the policy makers and decision makers to not only listen to the voices of those of us who have lived experience, whether it's mental health lived experience or substance use or those who live with disabilities, but also to include folks with lived experience in policy making and decision-making. It's critically important that we listen and include in the decision-making process the people who are actually being served by this process. So those are the two points I wanted to make and I appreciate the opportunity to share those perspectives with you. Thank you. All right, Alyssa's husband. Yeah, hello. My name is Danny Sagan, I'm Alyssa Dorske's husband. So I appreciate the opportunity to speak and I appreciate the goals and the situations that people are describing. Obviously there's a problem with paying for all this, but in terms of on the supply end, when we first moved to Vermont 30 years ago, we were much closer to Randolph and Randolph Gifford Hospital had a very decent amount of very good family practitioners, all MDs. And the reason they were all there was because of loan forgiveness. And they were basically moving to Randolph so that they could get their medical school paid for. And when Rebecca Holcomb was campaigning for governor, she was like, why are we educating nurses and then watching them leave the state? Because I teach at Norwich University, which has an exceptionally good nursing program. There's a great nursing program up at UVM. We educate nurses and then they leave. I think in terms of state budgets, one person's medical school bills is minuscule compared to the amount of trouble that this problem is costing so many of us. And I think that the state could create a program with not much difficulty to invite people to come practice medicine in Vermont by paying their medical school bills. And that would not be a huge lift financially. And the governor could even run on that. And I don't know why he isn't, when he actually is married to a healthcare professional, why he isn't running on that is a surprise to me because that seems to be a really easy win. So anyway, just thought I'd throw that out there. Thank you. Thank you. Yes, I agree that we need to get, not even creative but realistic with how we're bringing talent to Vermont and then keeping them. All right, Rob. I heard a lot of people critiquing the vote at the top. And I don't know if it's true or not. When I see some of the salaries, they're eye-popping. And I really do think, there's a lot of pressure at the top. They're very capable people in all likelihood or they wouldn't have gotten to those places. They carry a lot of burdens and they get probably tons of complaints and anguish in those jobs. With that said though, they really have an obligation if they're leading a public or nonprofit organization to lead by example, if there's belt tightening that has to take place. And when I was in state government corrections commissioner, the first positions and the disproportionate number of positions that we cut when we had to and were required by budget constraints were at headquarters. And then when I went on to HS human services, a disproportionate number of those cuts were at headquarters because you can't ask the rank and file and people providing direct service to patients and Vermonters to, you know, to track the job or tighten their belt if you're not doing it at headquarters and it's hard because those are the, it's a lot easier eliminating a position of somebody you don't see than somebody you work with every day and the awkwardness that comes with that and the fact you see the value in the jobs that they perform every day, but it's gotta happen. And so I'm not one to line up with pitchforks and pikes and torches to complain about the people at the top. On the other hand, they've got an obligation to all of us to, you know, be reasonable and in good faith, you know, have limited salaries and limited staff. Yeah, thank you for sharing that. Any other comments, questions? May I ask another question? Sure. I'd be very interested in what the current thinking is about one care and how that fits into the future of healthcare, the system here in Vermont. I am probably not the right person to speak about that right now. If there's folks on from the Green Mountain Care Board that would like to share kind of the overarching relationship, that would be great. You're welcome to. But I, from our perspective, I'm gonna hold off on kind of making a statement about the future recommendations and where those fit. And I guess to be more specific, address the cost-benefit issue of all the money that's been spent compared to the benefit we've received thus far, which many of us feel the cost way outweigh the benefit so far. That's helpful. Thank you. I can just pop on Dan and remind us that the Green Mountain Care Board occurred one care's presentation of their budget last week. And so we're in the middle of the Green Mountain Care Board's process of approving one care's budget. So I don't know if Susan or someone's able to give a timeline of when public comments are appropriate or will be seen before the board makes its decision, but it's certainly during this time where if you, Dan, or anybody wants to make the comment you just made in the form of a comment to the board, it's the right time for it. Absolutely, I'll put that in the chat. Thanks, Mike. Thanks, Mike. And Susan. You're welcome. All right. One more call for input questions that I can't answer or maybe try to answer. All right, well, thank you all so much for your time, for your input, for your vulnerability. I know a lot of you shared personal stories and I am just so, respect you all so much for having the courage to do that. It's important that we hear from you, but I know it's not always easy to talk about this. So thank you. We will be, like I said, kind of making our second rounds at the end of the spring or yeah, spring time, end of winter, beginning of spring time. And so I'll get in touch with our folks to update some timing for commentary, written commentary on the website and then stay tuned for kind of the next round of engagement, which will happen in March and April. Time frame. Hey, Elizabeth. Yeah. One more thought that just, I'm just reminded from an earlier question about availability of this meeting, it can't help but notice that Orca Media is on this meeting. And so if I have no idea where the Orca Media is recording this, but one would presume they are. So if someone was interested in that and that's where I would go as a first place. May not have been Oliver Wyman's intent, but there it is. Good to know.