 First item on the agenda is the Executive Director's Board, Susan? Thank you, Mr. Chair. I have a few announcements. First, the scheduling update. We will not have any meeting next or next July 4th. I hope that we will all be barbecuing and celebrating Independence Day with our friends and family. The other scheduling update is our press release is out for the month of July. We have copies on the table from the public and our website will be updated momentarily with those July meetings. It's a very busy month. Special public comment session, so please check out our schedule. The second announcement is that I will be reading a rate that the Board decided on this week. And that is, it's three dockets actually. The Board has issued decisions in dockets number 005, 006, 007 of 2018. These filings are affected for the third and fourth quarters of 2018. The large group POS right of the Board reduced the rate from 3.8% to 2.32%. For the small group my father, the Board reduced the rate from 2.1% to 2.8%. These orders are posted on the GNCB rest item is that I would like to add something to the agenda today and that is the Green Mountain Care Board budget update. So this is our own Green Mountain Care Board budget. We do have the starting July 1st for the state so we wanted to wait until all that was settled to give an update on our internal budget. So that would come, I guess it would be item number 4 after the off-air budget. The minutes of Wednesday, June 13th is for a motion. It's been moved and seconded to approve the minutes of Wednesday, May 13th without any deletions, additions, or corrections. Any discussion? Seeing none, all those in favor signify by saying aye. Aye. Any opposed? And at this point we'll go from the off-air model team up to the podium. Let's see side another college. So Melissa, Michelle, by providing the day the ACO programs focusing on the minimum requirements that an ACO program has to be qualified as a SCL target ACO initiative as well as on Hawaii. And Melissa will cover the information we will need to submit a report to CMS on how the 2018 programs compare in certain key areas. That report won't be due until the middle of next year. However, as we are thinking about the design of the budget Medicare ACO initiative and as we're getting ready for the 2019 ACO budget review process about the good opportunity needed to share our initial plan to discuss 2019 Medicare ACO program. As you know, we have the opportunity to deviate from the standard Medicare Next Generation program for 2019. We will describe some of the areas to their consideration. And then finally we're going to discuss all-air model reporting. So that includes reporting to CMS and legislative reports. As you know the all-air model reporting contained what we call SCALES targets. Those are targets for the numbers of Vermont Medicare beneficiaries in Vermont, all-air SCALES target beneficiaries that are aligned to a SCALES target ACO initiative. So essentially in order to be SCALES trigger to the life to count towards those SCALES targets under the SCALES target ACO initiative. SCALES target ACO initiative is defined as basically ACO arrangement that meets four requirements. First, the program has to offer a possibility of shared savings to the ACO. It achieves goals related to the quality of care and utilization. Second, ACO must be able to proceed whose 30% of shared savings is one of the responsible for shared losses, which is not the requirement. It has to be responsible for at least 30% of losses. ACO benchmark, shared savings, shared losses for accommodation have to be tied to the quality of care ACO delivers, the health of its aligned beneficiaries for both. So in other words, ACO's financial performance has to be tied to its quality. And finally, services compared to all-care financial target services and their associated expenditures must be included for determining DC and shared losses for shared savings. All-care financial target services is obviously a defined service. This is a definition of agreement. For Medicare, this is part A of our e-services, including the benefit enhancements authorized under a Medicare ACO program. And for other payers, they're basically comparable services, namely key hospital information and outpatient care, post-acute care, professional services, and general medical equipment for the end. So these are the four ACO programs or initiatives operating in 2018. One for Medicare, one for Medicaid, one for commercial program offered by the Department of Childhood and one for self-funded programming offered by the EVMC. We've given you a certificate of lives there for each of the programs as of the beginning of this year. As you know, the beginning of the year attribution is basically the high points. Attributions for the program, the number of attributive lives are expected to decrease throughout the year for the nutrition problem to the rates for different payers. Also, though for the self-funded program that contract was executed in May, which is kind of enabling us to do this across all four programs now, but it is effective for the entire calendar year. So as I mentioned, the first requirement for a scale-target ACO initiative is that there be a possible lead for the ACO from shared savings. Each of the four 2018 programs seems to supply those. Now the easiest slide that you'll have to say. The second requirement as I mentioned is that the ACO be able to receive at least 30% of shared savings and if they're going to be responsible for shared losses also a different percentage. This requirement also appears to be satisfying for all four programs for the Medicare program. There's a 5% risk corridor within which one care will be eligible for 80% of savings and responsible for 80% of losses. For the Medicaid program, it's a 3% risk corridor within which one care will be eligible for 100% of savings and responsible for 100% of losses. The Blue Cross program has a 6% corridor, 50-50 shared savings, shared losses, and the DVMC program is a shared savings only, so there's a 10% cap and up to that cap one care will get 30% of savings. So the 30 requirements are that the services be comparable to all payer financial card services for Medicare. Obviously that's met the services included for shared savings and shared losses of all Medicare Part B services for the Medicaid program. Comparative services are included including patient application to hospital care, professional services, home health and hospice and general medical equipment is pointed out while it's responsible for sending on general medical equipment for it's aligned beneficiaries that does not have GED providers within its network and is actually prohibited under the Medicare program from having those providers in the network. The cover services are medical services covered under and attributed to members qualified health plans, so those would be your specific health benefits, state mandated benefits and that contract also covers non-specialty parts. The self funded program for DVMC covers medical services under the community members medical benefit. I have a better understanding a little bit of what services are covered under but we expect that they are specific services. So last part for the scale target ACO issues is like I mentioned the DVC has financial performance to be tied to this quality performance so for Medicare 2018 is a important year, so the one care reports on quality measures in contracts and not between lines. Medicaid across and even in C, those contracts each require one care to create quality incentive pool based on the ACO's performance and quality measures in the contract. One care will be able to distribute some for all of the bodies to its network not that it's not distributed to the network half of that will go to the ACO for quality initiatives and half will go back to there. In addition to the sales target ACO initiatives requirements but related the all care model required ACO's programs to reasonably align in certain key areas including beneficiary, lightness, or attribution methodologies quality measures, risk arrangements payment mechanisms and services to determine shared savings and share losses. In the beneficiary, lightness or attribution, cautionary note here this is a pretty complicated topic and this slide affects our best understanding at the moment of how each of the four attribution methodologies would obviously try to simplify some but basically all programs use a claim space, perspective, align methodology under which someone can be attributed to the ACO so they have received a majority of certain primary care type services within a two year look back period from a physician or other professional that is part of the key differences potential differences that we think exist are that Medicare allows non primary care specialists to attribute a beneficiary, a beneficiary that is received by very few services from a primary care provider so that is not an option with the Medicaid contract or the other two contracts Second, the Medicare and Medicaid weight claims that occur in the most recent year of that two year look back period more heavily than previous in the first year so that is a very big case for commercial and self-employed programs there is a look at whether the number has selected a primary care provider so if your primary care requires a key to select a primary care provider then you've done so and that primary care provider is going to be ACO you're going to be treating ACO through that so the next key area for applying is quality measures and this table created outlines how the quality of the measures in the Medicaid across the shield in the EFOMC agreements have been done with the Medicare model and with the Medicaid out of the 12 measures along with the L.A. model measures for the commercial program in P.D.A. 12 U.M. C. bonus she's about this slide this table goes on to the next slide so the next key area for applying is engaged mechanisms and this slide describes those mechanisms between the payers and the Medicare full of Medicare and Medicaid programs this is a population-based payment for certain providers made this year of hospitals and those who have primary care practices that are just saving one care C.B.R. for providers on P.D.P. insurance for the E.C. programs it is P.D.P. for sure across the board there are now all places of population-based payments but there are things along here to support certain assets of its programs or operations trying to set those out there and setting their goals. The final alignment areas are in terms of risk arrangements and the services that are included for the P.D.P. check-states and check-bosses which are another of the previous slides so that covers alignment I guess support we move on to a different portion of the presentation again questions one question when we talk about the shared savings and the timing of the quality of the address do we have an understanding of how that would be what is aligned with the ACO as far as if someone this is one of the quality metrics I mean how much gets held back is there a table that goes through that yes there is a table for the Medicaid commercial and self-funded programs our understanding is they don't report I guess I think it would be interesting at some point to get an update from the payers around the amount of money that's being spent on that I think it would be interesting to get an update from the payers around what they're thinking about in terms of 2018 you all just think about the timing because it's being that ACO budget process but it's great that we hear regularly from our staff and from the ACO but it would be also nice to hear from the payers do you want to open it up to questions from at this specific point on what you've covered so far or wait until the end I actually have one other on the shared savings and losses obviously that will be determined after the performance year ends so that's quite a ways away but we should when it's closer be thinking about particularly for Blue Cross how the timing of getting that information needs to be the rate review timing so the two teams should at least start to think about that I mean we are really far in advance now but when it's closer and my cost from the evil is that as to all this there are those processes that the risk orders are going to hear themselves but Medicaid is the state program and subject to the I described in the beginning collaboration with CMS will design and launch the Vermont Medical Care DCO initiative to begin on January 1st, 2019 and that will be from performance year 2 to performance year 5 of the agreement applications to this initiative to align the initiative with other ACO programs operating in Vermont through Medicaid commercial and self-insured plans and so when the CMS agreement required the Vermont ACO to accept the attribution ACO quality measures payment mechanisms and risk arrangements for the overall quality and cost of medical care furnished in Medicare and beneficiaries aligned to the ACO. So the same categories that my interest spoke about earlier. So we have started discussions with CMS on our duties for the 2019 agreement and as outlined in the agreement there are three specific requirements that we need to work with CMS on. One is to set separate prospective Medicare benchmarks for the Asian disabled beneficiaries and the end-safe remuneration beneficiaries. As you will recall we did that in December of 2017 we will be preparing to do that hopefully in November of 2018 we will be defining our quality measures set for 2019 that Pat and Michelle will speak to and then we also need to set a percentage of the benchmark tied to the ACO quality as we were asking about earlier and we will be coming back with that session at a later date. So we've also been identifying operational modifications to support FES alignment and we are considering the governance requirements that Medicare has in their participation agreement for their board composition and that to match up with our rule 5 requirements for board composition. So we are currently discussing that with Medicare as well the beneficiary notification who would like to simplify and we are working with one character who is working with the healthcare advocate on that. And then I mentioned the last time we met that we are looking at the provider list that line for September to better align with our process here in order to get the benchmark data sooner. I mentioned the contribution but that's still in the very beginning status and until 2020 I'm here and I'm joined by Michelle and so we're here to talk about specifically the slate of measures that we are recommending between one pair and last for their 2019 model. So why are we proposing a quality framework? There's language in our agreement that specifically says that all of the scale targets of ACO and with initiatives including the Vermont Medicare ACO initiative incorporate provisions so that the ACO benchmark shared savings, shared losses are a combination of both. A combination is tied to the quality of care that ACO delivers to help with its aligned beneficiaries for both. So the agreement envisions that in 2019 the scale target initiative will have a quality framework. Now as they mentioned earlier in 2018 the ACO is responsible for reporting on the measures that are in the next gen framework that's a national framework at CMS and the next 30 some measures. For 2019 we have an opportunity where we can actually tailor the quality framework so that it links more closely to our all pair model agreement measures and really to Vermont's priorities and so our goal in working with one pair is really to have a framework that is more aligned between one pair to try and come up with a consensus set of measures. One pair started that process by really engaging our providers and consumers in a very extensive review process. They started with 44 potential quality measures. They really looked carefully at that next gen set and then also the all pair model measures and they reached out to over 100 providers and they heard back from about 40 of them, their leaders actually went into their communities and talked to medical staff groups or their community collaboratives. So they got a lot of feedback and they took it to their committees as well. They have a number of clinical committees. They have a population health committee, a clinical advisory board, a pediatric committee, a primary care committee. So they took this measure set around, went through the 44 measures, had the representatives from the various groups opined on the measures, ranked the measures. They also took the measures to their consumers as well. So they have consumer members and their board of directors. They have a consumer advisory group and those entities also weighed in on the quality measures. And they ended up with a list of 15 measures. And then the Office of Health provided a comment as well. That all took place in 2017. We were already thinking ahead about Shal and I sat down and had a series of meetings with one care and the health care advocate to see if we could achieve consensus on the two different sets. They worked terribly far apart. And so Julia Shaw from the health care advocate and Sarah Barry and others from one care participated. And we ended up being able to develop the consensus measures that proposed to CMMI. We did that CMMI took a look at the, we ended up with a set of 15 consensus measures. CMMI took a look at that, made some tweaks to it. We removed actually a couple of measures and so the consensus set that we have for your consideration and Michelle is about to present consists of 13 measures. We took CMMI's feedback back to one care and to the HCA so they're aware. And so our next step is to bring it to you for review and hopefully ultimate approval. You know we feel good about the progress that we've made here. I think you'll see when Michelle presents the set that there's quite a bit of a line between all care model measures. We also need to make sure we had some next gen measures in there as well because CMMI will have some interest in comparing Vermont's ACOs performance to how next gen ACOs are doing the actual. So at this point I'll turn it over to Michelle and let her go through. I believe there are 13 measures in this set. A couple of things that we're going to look at in alignment but in reality if you look at all of these measures they're just recorded in different ways. So there is a tobacco cessation measure for the Blue Cross Blue Shield program that's done through CAPS survey. There's also an all-cos-remission measure for the Blue Cross Blue Shield program which is not the exact same one that we have in the all-care model. So just to give credit for credit of this team, 2018 Blue Cross Blue Shield commercial program in the 2018 we want to continue to incorporate some of the measures to be able to compare Vermont's ACOs performance to national performance. These measures are holdovers from the ACOs shared savings program. So they're measures that are familiar to our providers. They've been well-mended with a good evidence base so they're measures that we've seen before. We present this to you for your consideration. We assume that it's usual. We don't want to see if there's public comment on this measure set. And then we really anticipate that there'd be discussion of the set. Hopefully it will work out for 2019. And for the future, and we've hit on this already but the measures are finding actual and to the ACO is another thing. And so we will be engaging in discussions about first of all which of these measures would be considered what we call payment measures. Where the performance of the ACO on these measures impacts how much they are paying. And then the second component of that really is how will performance impact some mechanism for determining how payment is impacted by the ACO's performance. So that's a little down the road. We'll continue to engage the ACO and ACA and CMMI in those discussions and anticipate that in the fairly near future we'll be bringing a proposal back to you in terms of payment and financial impact for your consideration. But the issue at hand is the slate of the measures that we present. So on the quality of the measures is it your plan to fill the cells for public comment today? Yes. And what period of time would we leave it open? I mean I would think of the because I realize next week is the holidays so maybe we'll do a 10 day public comment area. And with the possible load on July 11th. Does that work? Do you want to take questions specific to this now or do you want to... We'll just stay here in case everybody... So we did review some of these slides that will be back in May but wanted to go through them in a little bit more detail today. We wanted to talk about the total cost of care for the annual report. We've been working on that specification and we're really happy to say that we're in the final stretch of completion of it. It's nearing the end of the page specification and it's become quite complicated but very clear in the end. So we and CMMI will use this to calculate and validate our total cost of care for each quarter. And we at the meeting would see the mind alive to assess the specification. The review that I just completed of the contracts will be a part of the ACO scale target and the lineup report that's due in June of 2019. So we're ahead of the curve on that which is exciting. And then the first quality and health outcomes report is due September 30th, 2019. So each of these has been their own stream of work frankly to define what measures were specified and other stakeholders to take the CMMI. So we're very excited that each of them are almost complete and we'll be able to start calculating the total cost of care for the first quarter of 2018 soon. So down below we have the one time reports and the payer differential reports that are due. We have started the work on that as well. So the payer differential report examines the rates by payer and impacts if those have any differences on the ACM and it also examines network adequacy to determine that there are any significant differences among payers. For the agreement the Green Mount Care Board and AHS shall ensure that Medicaid is a reliable payer within the model. And so this may include any recommendations necessary to increase Vermont Medicaid reimbursement rates to levels more comparable to Medicare for service rates. You may recall that Medicaid had some pricing increases in 2016 and 2017 and we are taking those into consideration now and it will be also being put within the total cost of care specification for finalizing the all-payer model target specification. AHS reports and we will be needing a new director of health care reform soon on those to determine how we can collaborate. I believe those are a little bit further into the future. And finally, these are very small so I apologize, but they basically run through the first two years of our agreement for the claims incurred then when they are received in the years and then when they can actually be calculated. So this shows why we have a lag from the first quarter to the last quarter for the first report between the 18th. And then when we are collecting the information on the schedule part of the initiatives and when it will be recorded to CMS and finally also the health outcomes report. The first two quarters of 2019 on all of the data from 2018 for the quality of care reports. Going into the Act 124 reports which were, we just submitted a June 15th report on our performance year one of the ACO model agreement that's on our website as well as on the legislative website. We will have another one due in September and another due in December. And then we have a report due on August 1st to begin to look at the ACO attribution and scale target analysis and another one during November 1st of 2018 for the total cost of care and quality. We will see those this summer and now we are ready for discussion. Can I ask a question? Yes. There is a report due from the ACO on June 30th right? Yes, there will be a report due on it's a parent differential report that's examining their capitated pilot model and also provider burden. So that will be coming in shortly. So I have a question that relates to how this unfolds over time in terms of the total cost of care for example as I understand the baseline in this 2017 and sometime in the near future work moves forward versus make decisions about them that could affect, which is associated with those that think would affect the total cost of care, but those beds didn't exist in 2017. So how does the system accommodate changes in the infrastructure so I think for the larger question of how the impacts of decisions in other processes relate to total cost of care, we're working on some tools for you specifically around making things a little bit clearer as to understanding what certain decisions might be in terms of total cost of care, but in terms of things like the CLM process. So the all-air total cost of care group in your shared growth is a claims-based measure and wouldn't account for the cost of a long-term work. Your specific example of one thing to remember is as Mike went over earlier, there are only certain services that we are accountable for and for Medicaid, that's, I can't now remember the percentage of the total, but it is a smaller percentage than for example commercial or Medicare. And that was in part by design, because for example at the time we were negotiating it was clear that there needed to be investments in mental health. So I'm not sure if the site beds actually do count. That's something we have to go back to the 80-page stack and kind of crosswalk it back. But for example prescription drug spending we're not accountable for in the target. So I think there's like kind of a two-stage process of with particular new investments is determining whether or not their service is actually counted in the total cost of care. And then if it's something like an increase in Medicaid spending, we also have the provision that says for price increases we can be held harmless because the federal government wanted to incent the state to bring up Medicaid provider rates. And then there's also an exogenous factors clause which, you know, basically we could try to use if there's something really unexpected. And that analysis in part will be done through the parent to report each year? I know I asked you this probably, but I think it will be good to, you know, talk about in public the two quality measures that were dropped by CMMI and you know what the procedure was then go back to the ACL and talk about those. Because it was probably supplies I guess that CMMI would drop measures versus adding them. Yeah, I mean, again, I think what CMMI was really looking for was they were looking for what measures overlapped with the next chapter program. They wanted to make sure that there was a significant overlap there so that there could be that national comparison. And they also wanted to see overlap. There are keen interest in the line and if all payers are aligned then that means that there's some critical mass behind some of these quality curriculum initiatives. CMMI, the 15 measures that we presented in that asked us to drop the couple. One was pneumonia vaccination for older adults and the other was skilled nursing facility 30 day re-admissions. They didn't go into tremendous detail on why I didn't get the sense from talking with them that they were interested in having considered to be a reasonable size measure set so that providers and the ACL could focus in certain areas. Those were the two measures that they asked that we drop. We took that back to the ACL and HTA discussed it. Decided, I think I could let them speak for themselves if they wish to. So comment, but I think we decided that it was a pretty well rounded set of measures. It hits on chronic illness treatment. It hits pretty significantly on mental health and substance use disorder treatment which both they and we have identified as a key area. There are measures related to re-admission and unplanned admission so that speaks to the interface between ambulatory care providers and hospital providers. It obviously measures that they saw more related to children because of the population. We didn't actually propose those. We pleased that out of 15 measures that we presented to them that they agreed with virtually all of them. We thought that was a very good sign. There is a small numbers issue potentially there, so that might have been a little harder to calculate anyway. There is some volatility in that measure. So I can't speak specifically why. This has been a tremendous process from our standpoint that was very thoughtful engaging in termation directly on patient experience of care. So from our provider standpoint we really feel like we're in a good position moving forward into 2019 to be able to be able to do that. To be able to really affect some of the change that we all want to see particularly when it comes to the all-payer model goals and making sure that we are doing everything we can to support substance use disorder treatment and mental health concerns, chronic disease management, as well as making sure that we have measures and alignment around wellness care and prevention. So thank you very much. Thank you, sir. I also want to thank Pat for all of her hard work and all the remand care board staff for working on this issue and for including us in the process. We were happy with the 13 measures that came out of the process. I just wanted to also note that we did discuss keeping the skill nursing facility measure as a reporting measure and I think in general the HCA will continue to look for additional state oversight of quality within the ACO looking beyond kind of a negotiation with CMS and the things that the payers will be looking for having some additional board oversight of quality of care at the ACO. And we also will continue to work with OneCare and Diva and the board with trying to implement an additional patient experience measure around shared decision making something that would be at the point of care. So that's something we'll continue to work on as well. Thank you, Julia. Other comments or questions from the public? Yes, Susan? Susan Arnott from the Vermont Developmental Disabilities Council. I have two questions. One was for the year that ended 2017 which was supposed to be I guess under the APM terms year zero. If you go back a couple of slides there's any reporting for 2017 data that's being planned for. So I'm wondering when and how the Green Mountain Care Board is going to collect and report on the 2017 data. I know it was premature for the June 15th report that was just submitted but I was sort of expecting to see it accounted for in the charts that you had up there and I didn't see 2017 anywhere. That's one question and I'll just leave it at that. Next generation contract in 2017 and that was with Medicaid and OneCare does plan to present their results through Medicaid. Either in July or August we may come back to present this year. Medicaid is also doing quarterly reports on their implementation of that contract. 2017 is a baseline year so we will be using that to then calculate their forward but we are not starting to measure performance of the ACM until 2018. Do you have any questions? And we also reported to the legislature starting, I'm confusing my on implementation and those were... I would just, if it's okay, look to Sarah and Spencer but I believe the Medicaid reported the way it normally is through Medicare each fall usually issues report performance and that will be out there. Susan you have a second question as well. I saw another hand back in front of you. We're off topic here but since it's the public comment period I'm Deb Snell president of AFT Vermont and I just wanted to raise some concerns about what's going on at the UVM Medical Center with the nurses negotiations. As you know we are bargaining our contract with the hospital management right now and we're passing out a letter from our members that are on the bargaining team right now about where we're at and why we're in the position we're in right now possibly going on strike in the next few days or issuing our strike notice in the next few days. We have two sessions left and things are not going well. We are very far apart at the table one of the big concerns we have is the number of travelers in our institution. In the last three years the hospital has spent approximately $21.3 million on traveling nurses if we end up going on strike which is a very strong possibility at this point it's going to cost the hospital in salary alone about $1.2 million a day if they decide to lock us out for potentially up to five days it costs up to $6 million and that doesn't even include housing and we're well aware that the hospital is right now looking for hotel rooms for like 500-600 nurses and not doing so well with that. This is a huge expense when it comes down to our bargaining what we're looking for over the next three years for nurses salaries to attract and retain and keep nurses at our hospital and in Vermont our total package is right around that in March for the next three years so we're asking for support from the Green Mountain Care Board and the public that instead of spending money on travelers at the hospital invests in the nurses that are there and I also have with me Angela Pratt who is on the bargaining team. Yes. My name is Angela Pratt I've been a nurse at UVMMC for 32 years excuse me have a little cold and I've been asked to give you an update on our bargaining with Deb so we started bargaining March 29th and we've had 13 three-hour sessions. Our bargaining committee consists of about 30 staff nurses, nurses just like me, our union leadership, a couple of staffers and our lawyer. We worked very diligently to prepare for our contract bargaining and we on March 29th submitted our entire proposal package to our management team. They were not prepared to bargain back and it's a little bit typical and a little bit frustrating when we ask for specific proposals that we want to work on the ones that are stickier the ones that are harder to come to agreement on they would not hand them back and what they did hand us were proposals from three years ago verbatim things they proposed and the language was the same and it's for the nurses it would be a huge step backwards okay so when we work towards an agreement it doesn't really feel like our management is bargaining in good faith with us to the point that we sent out a question of a strike vote to our members there's 1800 nurses that work for UVMMC and about 1300 of them voted the 10th, 11th and 12th with a 94% strike authorization vote so to give the bargaining committee the ability to strike if we do not come to agreement. We have two sessions this week today and tomorrow if we do give a strike notice it will be on June 29th that will be a 10 day strike notice and as Deb was saying it's very expensive for us to strike because we go without wages and for the hospital to pay people to replace us. Basically it feels like infringing on our dignity to get to this point as the UVMMC network expands with us having connections with all of the feeder hospitals our population is getting sicker and we are getting much more acute patients one of our sticking points is that we are asking for safe staffing ratios. These are in alignment with a national American nursing association agreement. So what we're asking for is very reasonable. We want to take good care of our patients and we know we need to be staffed at a certain ratio to do that. So those are of course wages as our other sticking point as Deb said to retain and attract nurses we have to pay competitive wages so thank you very much. We are asking for your support in this upcoming week. Obviously we are not here to take any actions to support either side. Our hope obviously is that the two sides have a fruitful negotiation and that everyone wins in the end related to the all-parent model agreement. Seeing none at this point I want to thank you for your presentation and update for us and we'll ask Gene to come up in just a couple of weeks and there's probably a few more things that can be an initial idea when it was created and now the value to the legislature did this. If I ask our mission then if you look at our bottom left hand corner of the pie chart it shows what our funding ratio is where 20% is for our regular build-up fund and the next largest chunk is for global $1 million which come to us with specific guardrails to make sure they're being used in accordance with the federal and restrictions. One change that happened on our recommended budget is that we made a change in our requested house appropriations to make it about $211,000 for our base in blue level living on our base. This is a consistent one from the direction we received from our chair which is to be fruitful and also in time developing internal resources and data and policy in other areas to be able to use the knowledge that we've built in-house to strengthen this system and lessen our reliance on contracts and contractors. That's a shift that you can expect to see pulling forward. It also ties in the administration holding 3.5 in the overall weight of 1% general fund reduction. That's in alignment with our goal to be fruitful. 32 positions changed to the health care applicant. Our applicant was increased by a school year 18 in recognition for the base data on local care work. The change that you can see here is $110,000 to $111,000 is the change that I alluded to earlier with the $211,000 for changing limited service positions on our base, keeping those and reducing our basic contract. That's all shown in personal services and goes back to what the administration was saying. We pay for the services even if we are overall lower than we were in fiscal year 18. This is somewhat disordered but it includes the $1,000 that the green health care board received for the same credit change over time. We are 18 in fiscal year 15 to 18. Our general fund has increased as well. If you follow our budget over time you can see the amount that we are building back has increased in recognition of the fact that we have lost federal and local government funds so funding changes. The change that we asked is for this change to spend $8 million on the DFR prior to the board's creation. And the green health care board will take a broader review than the DFR did prior to 2014 and the valuation for fiscal year 18. You can see for blue crops the shield in the green health care board's decision. There were 14.4 million in insurance population and when you key, there was $1.8 million in savings to the green health care board to ensure population. The rate that was approved is lower than the rate that was proposed. That patient revenue increases which is one of the benchmarks that is used by the board. You can see that over time, you look at the last six bullet points you can see our bars on the bar graph. You can see the increase in the assistance and why much more we have to demonstrate that the work of the board is increasing the value. Are there questions or comments from the public? Use global commitment in those charts. So global commitment is our federal Medicaid money and I'm just wondering when you're talking about global commitment and what the board has lost, if you're meaning just federal dollars or federal and state dollars. In this case for the green health care board, it is federal money. You've got two federal money, the same grant. It's fake and federal. I think the board has taken some pretty meaningful steps in the budget process to try to provide even more value to the monitors and I look at just what's happening with the build up of that expertise and how it seems to make a real common sense to employ the monitors and do something about them and pay an outside contractor who's not living in us. So I think it's a real meaningful step. Thank you. I just have something to report of substance organizational and getting started on... Super, is there any other role of business to come before the board? Seeing none, is there any new business? Seeing none, is there a motion to adjourn? Second. It moved and seconded to adjourn. All those in favor signify by saying aye. Aye. Any opposed? Thank you everyone. Have a great day.