 So I am Betty Keller from the Vermont Physicians National Health Program. I'm the president of the Vermont chapter. I'm also the co-chair of the Education and Advocacy work group for one pair of states. And I'm on the health care committee for the League of Women Voters of Vermont. And for full disclosure, I have absolutely a financial interest in Medicare, but so does every other American. So no American can talk on this topic if everyone with the stake is disqualified. This is important to all of us. It's been a public program and the Medicare privatization, which includes Medicare Advantage, which we've had for several decades, and Reach, which is newer, formerly known as direct contracting, are threats to seniors in the future of Medicare. You can find out more information about this and see updates at the website protectmedicare.net. So what is Medicare? Most of us know that health insurance is, it's health insurance for people who are over 65 or disabled. You pay into it while you're working, and then when you become eligible, you pay premiums for parts of it, and Medicare pays part of your healthcare expenses after you pay deductibles. So we'll look a little bit more closely at traditional Medicare. You can find more details at medicare.gov. But part A is the hospital insurance, and the vast majority of us have no premiums if we've been paying into it while we were working or if we had a spouse who was. Part B is outpatient care. In that part, you do pay premiums and you have a deductible and co-insurance. Part D is for drugs, is the mnemonic. So those are for prescription through a private company. The insurance is provided through private companies that are regulated by Medicare. Medigap is what people will buy as supplemental insurance to give them an out-of-pocket cap. So if you, for instance, had cancer and you were paying for your deductible and then your co-insurance on all the images to figure out the diagnosis, all the studies you might've had, all the, you know, if you had radiation therapy, chemotherapy, those could really add up. And so Medigap gives you a cap where after a certain point, you won't be paying any more co-insurance you'll be done for the year. And it can help with other expenses that aren't covered with healthcare that's not covered by traditional Medicare. Vision, dental and hearing are generally excluded from these and you can purchase those insurances separately if you wish, again, from private companies. So Medicare Advantage was developed as with the concept that value-based care would change the incentives so that doctors and at that time it was primarily doctors weren't incentivized to give more care than you actually needed to be able to charge the fees for the services they provided. And instead the idea was that they would be charged to keep you healthy. So it would get a monthly fee and that would pay for your medical care and then they would provide the care that you needed. And the program would also have to pay for the images and things like that. So they pay a monthly fee to the providers to, I'm sorry, Medicare pays a monthly fee to Medicare Advantage and the Medicare Advantage pays the doctor's monthly fees and they pay for the images and the other things as well for the seniors and those who are disabled. So it covers medical care A and B and maybe also D but not necessarily. It may actually cover dental vision and hearing as well and they are allowed to charge their overhead expenses and also to have profit that they can keep up to 15% total of overhead plus profit. So if we compare traditional Medicare and Medicare Advantage this image shows the doctor or other healthcare provider getting paid directly by Medicare. In this one, you see that there's actually in Medicare Advantage, there's a middle person between the provider and the Medicare program. So how do Medicare Advantage plans make money? The idea is that they are looking at ways to keep you healthier so you don't need to use as many medical services but they are allowed to keep profit and overhead. So whatever they don't spend on those medical services they're actually able to keep. So that's a dangerous incentive, to ration and restrict seniors care which do not exist in traditional Medicare. So where are the different places that they can make money? One way is to minimize the revenue that they spend on patient care and the other is to maximize the revenue that they get from Medicare, that monthly payment that they get. So we'll tease out a little bit minimum expenditures where they try to save money. They seek patients that don't use a lot of services and historically one way to do that was to put their signs up in gyms, for instance. So the adults who were healthy enough to go to the gym were thought to be maybe not as likely to use up as much healthcare services. They also limit the care available for expensive conditions so sicker patients believe. Like you may have thought, well, I'm pretty healthy, I'll take the Medicare Advantage program but then when you actually got sick it didn't cover you so well, so then you left. One of the ways that they limit the care is to limit the networks of the doctors and hospitals. So for instance, if you have a very expensive autoimmune condition and they didn't cover the rheumatologists that took care of the more complicated situations. They didn't cover the hospitals needed for the most expensive care. You'd have a list of hospitals that were in network but they wouldn't cover the ones that had the burn units or the more expensive cancer treatments and they didn't cover medications that are needed by the expensive patients. So even if it was not that super expensive of a medication but it was needed by people who tended to be more expensive they might choose to just not cover that. Then the other thing that they do is maximizing the revenue that they get from Medicare. So by up coding to make them look sicker than they are then Medicare Advantage could get a higher monthly payment regardless of how much care they actually received. So I'm gonna talk to you a little bit about coding. Medicare used to pay them just based on, they paid them Medicare Advantage plans the same amount each year for each person just based on age. So if you were older they would give more money per month to the provider. But as you can imagine some people have way more expensive conditions. So that was part of what was leading toward them, they call it cherry picking where they're trying to get the least expensive patients to take care of by advertising in the gyms. So now they introduced in 2006 these diagnostic codes for chronic illnesses so that places wouldn't be as likely to try to lemon drop get rid of them more expensive care for the care for the more expensive patients. So let's look at an example of the up coding. Well, here's the coding. You can see that the baseline previously would have been the 0.45 just based on age and then they added these other codes. So for instance, just obesity is not given a particular number on the score type two diabetes, you would get 0.104 in addition to the baseline fee that you got per month. Major depression, well, zero asthma was also zero when they don't give any more descriptors congestive heart failure was 0.323. So in this patient with these history of these conditions that Medicare generally would typically pay a Medicare Advantage plan $9,000 for the year to cover for their care. Now, what does the up coding do? If you actually specified that it was actually morbid obesity so it's over a certain amount of the body weight then it would be 0.273 instead of just zero. If you identified that they had retinopathy which is something in the back of your eyes then they could give you 0.318 instead of 0.104. For major depression, even just specifying one single episode of major depression and it was a mild depression. They still could give a 0.395 instead of just zero. It's like, how is that different? That's like the most mild it could be but by being specific you could get more. The congestive heart failure by specifying that it was class three then that you get 0.323. So if you see down the road by being more specific and trying to make the person look as sick as possible even if they were walking around and going to the gym for instance, you could get an annual payment up to $32,000 per year. So if a Medicare Advantage plan is making that much money you can appreciate why they would be able to afford to offer extra things on the plan like dental vision or hearing. Although there's another thing on why they can do that too with the federal government setting aside some money to help them with that. So people are living longer and less than half of them were choosing Medicare Advantage. So these corporations on Wall Street are looking to see how can they get profit for the rest of the people who choose to stay on traditional Medicare. It's just a big pot of money that they don't wanna let go. So what is Medicare Direct Contracting? When the ACA, the Affordable Care Act was passed in it there's a little clause that says that direct contracting entities would be able to do innovative programs and start up these value-based plans just with having the center for Medicare services has a unit that was created called Center for Medicare and Medicaid Innovations. And so that subset of the Medicare program can choose to agree to let a new entity provide one of these value-based plans. They call it value-based plans. So direct contracting is where an organization contracts directly with Medicare to provide these services and then that program was getting a bad name. So they change the name and a few features but it's really essentially the same thing to this other program called ACO Reach. So what are these programs? So say you signed up for traditional Medicare and you expect to see whatever doctor you want to see, you have a primary care doctor, you've known a long time when you travel to visit your kids or whatever, you wanna know that you can be taken care of in the nearest hospital without worrying about networks and you don't wanna worry about, oh, what if I cost more than I usually do? I don't know when I might get sicker. So I don't wanna have these narrow networks and type formularies and things of what medications are available. So say you've chosen traditional Medicare but you can be aligned to one of these doctors or you can be aligned to one of these programs if your doctor chooses to go ahead with one of these contracts and your doctor may not even have wanted to but they are employed by a hospital or a clinic that chooses to sign up for one of these and the primary care doctors have big incentive in areas where this is happening, everybody incentive to do this because they get paid a monthly fee to manage your care. So Medicare makes a monthly payment to these programs to manage your care and the money like in the Medicare Advantage, they can go toward Medicare, overhead and profit. So remember seeing this picture before with the middle person between the provider and the Medicare with these new programs you actually have private equity firms trying to get a cut from that middle person, that middle program that is making money off of the Medicare Trust Fund. So how do they differ from the Medicare Advantage programs? The Medicare beneficiaries who are in Medicare Advantage they chose that plan, they weighed the savings that they would have per month versus the risk that they got sicker and those who are in the put in the DCE reach plans did not choose them, they may have made specific points of choosing the traditional Medicare, they typically pay more than a thousand dollars more per year for the benefit. Medicare Advantage plans can keep up to 15% of overhead and profit, but the DCE reach plans can keep up to 40% if they are able to spend little enough on your healthcare. Medicare Advantage was approved by Congress and these DCE reach plans have not been, they were introduced as a possibility in that one law but each of these new plans that go in they have not met rigid criteria like Medicare Advantage had to. So why should we stop the direct contracting and ACO reach program? What is, what's the big deal that you're seeing more of it in the news as time progresses? The problem is that Medicare has listed on its website even that has a goal of transferring all Medicare fee for service beneficiaries as they say into a care relationship with accountability for quality and total cost of care by 2030. Now this is a radical transformation and that's just eight years from now that they want everybody who's in Medicare to be in one of these kinds of programs where there is an incentive to deny care to try to reduce the likelihood that you will get the more expensive treatments. So there are a couple of reasons and one is that it threatens Medicare's solvency like will there be enough money in the trust fund when we get there? And by having all this up coding there is a huge threat to the solvency. There would be plenty of money if there weren't the caps on how much can go into it from your income and if we weren't wasting money on administrative waste and profits. The other thing is that it threatens seniors' help and their healthcare choices. As we spoke about that when you're in one of these programs it can be harder to get the care that you need. So in the solvency issue you can see that in traditional Medicare there is only 2% spent on overhead and there's no profit. And so 98% of the care goes to patient care. The Medicare advantage up to 15% can go for overhead and profit. And the patient care will only be spending 85% of the money would go toward patient care. With these ACO reach entities they won't all get up to 40% but they have the opportunity to get up to 40% of their funds from Medicare going toward overhead and profit instead of going toward patient care. So how do seniors end up in these ACO reaches? Their primary care doctor or their doctor's employer will sign a contract with one of these reaches. It's also not clear but it may be that the managers of their retirement plan may sign a contract with one because these are innovations the plans aren't all the same as each other and things can change and we don't exactly know where things will go with them. How can you get out of them? Well, one way is to change your doctor but you'll recall that the goal is to have 100% of people on something like this. That means over time there would be no doctors who were not in them. Another would be to lobby your retirement plan to make sure that they know that you're looking at this and that you don't want them to sign up with them. But it may be more effective to work to stay out of reach than to try to get out once your doctor or plan is put in it. So to try to raise awareness among physicians to please not sign up for this and if your local hospital is signing up for it talk with them about why this is not a good thing for our community and for the public good. And the other is to try to stop it so there doesn't exist so they won't be signing up for it. Why isn't Congress trying to stop it? Well, one thing is that until recently most of Congress had never even heard of direct contracting or ACO reach. In January, 54 members of Congress sent a letter to Health and Human Services demanding that we end the program. And the process of getting those numbers of Congress to sign a letter was an educational tool so they even will heard about it. And now later in January, maybe it was February they actually reviewed the program, realized that it had a real marketing problem that people were getting angry about it. So they said that the DCE program will end at the end of this year. So no new ones are signing up for that and they're gonna start this ACO reach program instead as of January 1st. So anybody who wants any private equity firms that wanna get involved in this they can be going through the process now but not start until January. And there's so much money at stake that they are fighting hard to protect their opportunity. They make profit on this. So what can we do to stop this on May 23rd? On that is a Monday at 1 p.m. there'll be an online Zoom type of program turning up the heat on direct contracting and reach summit. So so far PNHP and allies like Social Security Works have been focusing on trying to reach out to legislators. And what they're hearing is that, oh well, we're hearing some complaints about Medicare Advantage but nobody's talking about DCEs, nobody's worried about them. So what we're doing is reaching out to more individuals and telling people, tell your legislators that they don't think it's a problem, tell them it is a problem. They need to be looking at this now and get this stopped. So we're hoping that as many people as possible will attend the summit, spread the news, tell other people about it. It'll only be about five minutes worth talking about what DCEs are. And then after that we'll be talking about what do you do about it? How can you become active to try to stop this program? For individuals, you can also sign up and share, sign and share the petition to stop Medicare privatization. And you can find this address again on that webpage I had shared earlier in the beginning of this presentation. You can also write a letter to the editor in your local news outlet. And again, that's protectmedicare.net to get guidelines on what to put in your letter. If you belong to an organization, you could chat with the rest of the board or if you're not on the board, then talk with the leadership and ask them to sign on to the ACO reach and Medicare privatization petition against it. And also try to get more members of your organization to sign. So again, that's the webpage protectmedicare.net. And that's the end. I have some extra slides if they happen to match up with what people have questions on. So we should, let's see. So we're allowing participants to unmute themselves. Good. Okay, so first I'd like to ask folks to ask questions that they have. If you have comments that you wanted to share, if you could wait on that for a minute to see what questions people have first. So if you have a question, you can raise your virtual hand if you see at the bottom it has a reactions and you can click on that and then see the choice for raising your hand. But since we're only on one screen, I can actually see if you just raise your hand. Rebecca, do you wanna unmute yourself? Two part question. What percentage of Vermont providers are linked to the ACOA reached and how do we find out who they are? Well, thank you. Actually, I'm gonna let Ted talk about that because Ted Cody is my secretary of BNHP and he's looked into this a little bit more and Marvin Malek is here too. If you could unmute yourself, Marvin, then when you have something to add, you can help out too. He's the past president of BNHP. So Ted, do you wanna talk about that? Thank you, Rebecca. I'm a retired internist and have occupied myself with some of these issues. All my patients were of Medicare age, put it that way. The information is that in the state of Vermont, only 13% of all Medicare recipients are on Medicare Advantage. That's lower than the rest of the country, but the local insurance companies are starting to market much more heavily. There is one ACO reach practice in the state so far. It is located in the Burlington, Essex area. It's called Evergreen Family Practice and it subscribes to an ACO reach corporation called Clover Health, which is a organization that has promised physicians in Vermont up to 40% improved profit per patient. And the way that they're going to do that is they have a computer program which has a nice cozy name to it. And when you go to, if you visit one of these Evergreen Family Practice physicians, the first thing that will come up on their computer screen is this computer program developed by Clover Health, which by the way is all venture capitalists has nothing to do with health. And the purpose of that program is to achieve the most efficient degree of up coding as Dr. Keller so clearly set out. In other words, if there's something that might make the company more money, the computer will tell it that. It's kind of hard to tell whether the doctor is treating the computer or whether it's treating you. But that's the answer in Vermont so far. I'm sure there'll be more. Did I answer your question? Right, so we only have one. So when Vermont P&HP spoke with Senator Leahy's staff a week and a half or so ago, they were, well, yeah, nobody really cares about it. It's Medicare Advantage. We're getting way more calls about Medicare Advantage now than we used to, but they aren't hearing from DCE folks yet, because it's just so new. Marvin, you wanted to share something? Yeah, I didn't want to interrupt you. Finish what you're saying. Well, I did want to also just say ACO Reach, just to give you the name, ACO is Accountable Care Organization and Reach is Realizing Equity, Access and Community Health. So basically, the direct contracting entities was too easy and a target. So they got together with some PR people and said, well, should we call this instead? But the program is very, very similar. There are a couple of things thrown in like you can actually make more money by documenting the data of how many people you are surfing who are from marginalized populations, but you don't actually have to improve their outcomes or anything. You just have to document that they're in your program and you can make more money. Yeah, Marvin, go ahead. During this earlier in the talk, thank you, Betty. It's a great talk. Earlier in the talk, Betty mentioned that the goal of this autonomous center within the Medicare program is to enroll every single person in Medicare either into a Medicare Advantage plan or in one of these deals. And there's actually a variant of ACO. They're largely similar. That we have an heavy dose in Vermont, which is the old kind of ACO. Structurally, it's not fundamentally different from the ACO reach, but pretty much everybody who gets care at UVM or one of any part of UVM's empire who's a resident of Vermont is part of this other ACO that's been around for a longer period of time. It's called OneCare. And OneCare, as is the case with the rest of the new reach program and the Medicare Advantage plan, they all have not saved money for taxpayers, quite to the contrary, they've extracted money out of the Medicare Trust Fund. And in fact, there was an article just published yesterday in the Journal of the American Medical Association, very prestigious journal, pointing out that the Center for Medicare and Medicaid innovation that's corraling, that appears intent on corraling everyone in Medicare into one of these deals, these DCE or reach deals by 2030 that the program is a remarkable failure. They've had 50 different variants of this. And out of 50, only six of them have actually even saved a little bit of money for the Medicare program. And if you figure it's either gonna save money or not save money, it should have been that on a random basis, 25 of them should have saved money, but it was only six. So it seems like the model, as Betty pointed out, the model is so heavy on administrative, on gratuitous, unnecessary administrative effort and cost and numerous, numerous employees that the program, and then leaving aside all the profit that the program, you can see why the program is losing money for Medicare. You can make an argument that the private equity firms like the one that we have in Vermont, this Clover deal, Clover Health, that it's probably worse, they're probably more mercenary. For example, United Healthcare, the nation's biggest private insurer, which now has ever bigger inroads in Vermont, they're absolutely mercenary about denying care. Like we've had a bunch of patients where I work at Springfield Hospital, but we don't get paid. They just deny payment for the hospitalization. It's unbelievable, it's just unbelievable. Like if you're in Medicare and you get hospitalized, there's a book that tells them how quickly to dump you out of the hospital, how quickly you should be discharged, like one day, two days, three days and the book has this formula for each problem like hip fracture. And, but the program is based on the idea that you have a dozen family members at home, all of whom are muscular, all of whom are very medically sophisticated, who can totally take care of you. And if that's what you have, then yes, you can go home one day after a hip fracture, but not everybody has that waiting for them at home. And it's like unbelievable. And if you fall out of those criteria, you just don't get paid. And this is in common between the Medicare Advantage insurers and the private, the DCE and reach ones. It's all the same. It's very demoralizing. And to work as a doctor and this is, it's just very demoralizing. We try to do our work. And then even if we have a great outcome, not even to get paid is just very demoralizing. It's disgusting. But I'm not saying that we're worse off than the patients because they're being hurted into managed care that they don't even know about. And I just think that's appalling. I just think this whole thing is appalling. And I hope that all of you will write, even though Bernie Sanders has signed the letter and he's on the right side of this. And so is Peter Welch. Write them anyway. Tell them to do more. They need to do more. Lay he should do something. Lay he should go talk to Biden. Tell them to get this under control. It's ridiculous. Sorry, I'm sorry to talk for so long. Marvin brought up a good point. Oh, let me hear from Mary Alice first. Go ahead, Mary Alice unmute yourself. Mary Alice, you're muted. Yeah, she's trying to find it. Well, Mary Alice is looking for that. Oh, I'll go ahead. Oh, you still haven't figured it out. It's in the lower left generally, if you bring your mouse down to that area. There you go. Are you? Yes. You get it. I have a new Chromebook. It's a new Chromebook. And it runs just a little differently. I've been following a lot of this and I've been following in the legislature. I still want to know what is value-based care because they were going to have all kinds of money they were giving to the Green Me Out and Care Board to find out about value-based care. The other thing I wanted to say that I do have UnitedHealthcare. I've had it for years and years and I'm grandfathered into something called the Plan J. I pay a whole lot of money, like $234 a month for a copay, and they're raising it again in June. So they're telling us that the only thing UnitedHealthcare is raising are people that aren't on Medicare, but they are raising it for those of us who are on Medicare also. I have to find the letter. My filing system is terrible, but somebody at Digger is going to be doing a little research on that. So I'm hoping that'll get figured out, but I just wanted to mention that. And value-based care, what is it? And why can't we do fee-for-service? So that's a really good question, Mary Alice. So the concept behind value-based care, in theory, it sounds good. Oh, well, if you get charged fee-for-service and the more services you give, then the more you can charge, make more money, and the more things you buy, you sell them, like maybe medical devices, wheelchairs, braces, whatever, the more things you sell, the more money you get to make, right? And the idea in value-based is that you remove that incentive, instead of getting paid for every single thing, you get one fee, and you try to manage their care and reduce expenses by not ordering duplicate tests, for instance. So if you have one managed care organization that centralizes all of its studies, and say you have an x-ray done by your primary care physician at one hospital, and then refers you to a tertiary care center where there's specialists, and they want to repeat the x-ray because it's not their x-ray. Then you've played duplicate services, and if you're in a managed care program, they'll figure out how to use the first x-ray. They won't repeat that. But the reality is that we don't need to have those kind of motivations unless you have an oversupply of doctors because you don't have any incentive to try to see people more often if you already have a long waiting list, and patients don't typically want a second x-ray. They don't want to take more time off from work to go get something that they don't actually need, and they don't want to take more drugs than what they actually need. So where is the overutilization coming? When they've done studies, there are a couple of things in some cardiac interventional procedures, for instance, that there are more being done than is maybe healthy for the public. And so we should attack those specific things. But overall, when you compare Americans to people from other countries that have healthcare systems that are not based with any profit in them, you'll see that we see doctors less frequently, we get hospitalized less often, and we get discharged from the hospital faster. We are not overutilizing care. So the paradigm of thinking, oh, we need to get rid of fee for service is just really a false notion that if you had an oversupply of everything, then you'd have to figure out how to reduce overutilization, but we do not have overutilization right now. With the value-based care, the idea has been that, oh, we'll get more value, more bang for our buck. You'll save money on the healthcare, but the only way to do that is to either have people use less of it or to not get the people who need more care. I mean, basically your motivation is to try to get people who don't need much care. So when they say, oh, we want to have value-based programs that either improve quality without increasing cost or reduce cost without reducing quality. When you say that, you say, well, right off the bat, we don't have a lot of places to cut from if we only have a 2% overhead and we're not overutilizing. Medicare is not overutilizing and it's only 2% overhead. So how where are you gonna cut from that? You can figure out specific things if there are overused things, you can require that specialists use the first X-ray and not repeat the on on their own machinery. You can do little things like that, but that doesn't require overhauling the whole system and overhauling the whole system will not improve it. So in the law, it says that it's not supposed to increase costs, but we're not seeing, they're not showing us the data to show that they are improving quality and keeping the cost the same or cutting the cost without harming the quality. We're not seeing that data. Like last week, there was something in the New York Times, Marvin mentioned something that came out today in this medical journal. So we're seeing things that contraindicate it, but contradict it rather, contradict it, but we're not seeing data that supports it. So I wanna see the numbers and it doesn't make sense to me that it's actually realistically possible. So I really wanna see the numbers of how they're doing that. One thing is they might not be showing the waste that happens in hospitals if they're only showing how much it costs from the provider's point of view. But if you look at how much it costs for hospitals to deal with this, you would immediately be seeing that this costs more. Now, if somebody had their hand up, Mary-Elser. I wanted to mention also the auditor of accounts did a study about that and found that it actually, it was not one care that was saving money, it was other parts of the state where there isn't even a one care. And it's just ridiculous. Yeah, yeah, agreed. Can I say something? Yeah, if I could just reinforce what you said, Betty, in a slightly different way. The idea of value-based care is if you pay a physician a set amount per patient and that set amount is independent of how many visits and so on and so forth, then the physician, his or herself, will choose to not do anything unnecessary and will somehow make things more efficient in the long run. Two caveats to that. Number one, no physician has 100% of his or her patient patients in these value-based care arrangements. So it's impossible to give one standard of care to your fee-for-service patient and another standard of care to your ACO patients, for instance. Second, and let me be a little cynical about this. The way we measure value is by means of roughly 50 criteria in the case of one care. In other words, have you been able to get your diabetics to a lower average hemoglobin A1C level? How many rectal exams did you do and this kind of stuff? But in reality, the physician, the practice, the ACO, the DCE, the reach, whatever you call it, does not get penalized unless they come up on one of those 50 criteria. In other words, you can cheat the patient however you like as long as you don't get caught by having a lower average of one of those criteria. That's what it boils down to. Sorry to be so cynical. It's a really frustrating thing for providers because you're trying to keep your practice open. You're trying to stay in business because if you can't afford to stay there, then your area will be underserved, right? Especially if you live in like a rural area of Vermont. But the motivations are just, if they just would improve the reimbursement instead of having to go through all this other stuff, doctors would have more time to talk to each other. They wouldn't have to be depending on a computer telling them something. And you wouldn't be paying extra people to go through the charts and figure out where they can save money in all. Marvin? I just wanted to amplify what Betty just said. Doctors, so the doctors this is gonna impact the most are primary care doctors, correct? But they account for tiny fraction of overall spending. The specialists who are earning hundreds of thousands of dollars, they're gonna be fine. I mean, I think the goal of the program was to somehow decrease overall spending but why you're picking on the primary care doctors is beyond me. If somebody needs an operation because they have colon cancer, being in an ACL reach is not gonna change that. They still need the surgery. And I think the biggest fundamental problem is there's no evidence that we're providing a lot of unnecessary care in the United States. And also there's no evidence that even though there are variations in the amount of care that's provided in different counties and different parts of the country, they've actually experimented with changing payment models and it doesn't affect it. That our doctors decisions about what treatment to give is pretty much always based on what they think is appropriate and necessary and what the patient wants done as well. So, and that's really how it should be. But going back to primary care, so primary care doctors are paid the least pretty much of all the specialties, pediatricians especially. And so the one in Vermont, the evergreen practice that Ted was talking about earlier, which has sites in Chittenden County in Charlotte and Williston, they are trying to stay independent of UVM. And so this is a scheme that every time they activate the Clover Assistant, which is the software that Ted was talking about, they get $31 from Clover just to activate it. And the Clover Assistant software program in their computer queries the doctor to try to get them to elicit lucrative diagnoses, diagnoses that'll increase the up coding and allow Clover to extract more money from the Medicare program. So in the sense the $31 going to doctors is a kickback for a scheme to extract more money from the Medicare program. And so they're putting doctors in this position instead of paying primary care doctors an amount of money that would make it a semi competitive specialty compared to neurosurgeons and ophthalmologists, they put us through these shenanigans where we got to start logging into the Clover Assistant and interact with it. And supposedly it takes five minutes. That may not seem like a lot of money, but if those of you who walked into a doctor's office and had a visit, how many more than five minutes do you get with the doctor? Like you get 10, this extra software gets five and their own software, which they still have to deal with gets a certain amount of time too. So this is directly bad for patient care because it's a diversion. The doctor's not gonna be able to schedule more patients. The doctor's trying to get the $31 each time somebody and enrolled in this Medicare who goes to Evergreen in the Medicare program walks in the door. So it's a big diversion, but it's basically a scheme. It's a kickback scheme from the doctor's point of view. And I just think it's reprehensible that this is what primary care doctors have to do to try to stay independent of one of these monster organizations like UVM or Dartmouth. You can't maintain autonomy anymore. I see Mary Alice has another question. Does anybody else have a question they would like to raise? If we go ahead, Mary Alice. Well, I know the May 23rd meeting is supposed to talk about things that we can do, but I haven't had any luck and writing to my congressman. They called me back and talked to me about media and talked about other things. They tell me all these wonderful things, but they don't ever mention healthcare, even though that's what I'm asking them about. And I'm just wondering whether... I had read some stuff a long time ago because I've been doing some research too that back when CMI was put into place the Congress doesn't have any more contact with CMI. And how can we convince them that they need to get involved? Is that what the May 23rd meeting is gonna talk about? Yeah, the May 23rd meeting will be talking about what individual citizens can do to try to make a difference. But I can tell you a big part of it is reaching out specifically actually to Senator Leahy's office. So he's in office for one more year. He's not running for reelection. He's gonna retire, but he's there for this year. And right now, there's a lot happening on this. This program started, it was put into the ACA law during Donald Trump's tenure. They started to do a few of these programs. You had to have a program for these direct contracting entities. They had to be built on a pilot done somewhere else. So OneCare is actually a pilot for these things, which is why CMI has been working so hard to make sure it works, you know, or that it's sustainable or whatever. And when I say it works or it's sustainable, what I mean is that it will meet their criteria for being able to base a direct contracting entity on its model, not that it's actually sustainable for us financially or anything. But anyway, so and Senator Leahy's staff said, we're not hearing anything about that. Nobody's talking about it. We, you know, we'll keep our ears open, but they weren't taking an active role. The thing is that our legislators don't have to pass a bill on this because it's entirely under the auspices of the executive branch. So if Secretary Becerra were to decide to stop this program, it would stop. He could just like say the word and it would stop. He's not gonna do that unless President Biden is on board. And President Biden hasn't seemed to take any notice and made any comments about this. And of course, we know that he's been totally behind the support of the Affordable Care Act and has not wanted to pursue a single payer type system. So he's just thinking in terms of, oh, well this within the ACA and I'm supporting the ACA. But we need to let him know this is not a good part of the ACA. This is something that should be changed. And so we want to have people reach out in ways that will change the deciders. You know, the decision makers minds and I don't know what that is. I'm looking forward to finding out on May 23rd what they're recommending. But in the meantime, I know that contacting Leahy's office, Senator Leahy's office and asking his staff to do what they can to put pressure on Becerra and on President Biden saying this is the bad thing for our Medicare programs. It is robbing the trust funds and it's harming seniors' health and it's harming their autonomy. When they chose one kind of plan, they decided to be in traditional Medicare and they're taking away their choice. That's just, that's reprehensible. And so stop it now. We don't need to wait for any laws to be passed. There could be a law passed to also require that it underwent more restrictions and more overview. But trying to get anything through this Congress right now, I mean, seriously, when there's an executive branch decision path that could work instead, it seems like that's the way to do it. And we should be doing it now. So the current direct contracting entities are only through December 31st and the REACH program, they're applying, the companies are applying to become those kinds of programs but they can't start until January 1st. Basically kind of a little hold on it. Margaret, you had a question? Margaret had, yeah. Thank you. My question is, you mentioned the secretary's name. Can you say that again and maybe spell it if we need to? Are you able to see the chat? So it's Secretary Becerra. Becerra, okay. V-E-C-E-R-R-A. All right, great. Thank you. And she's the secretary of health and human services. Is that? So he is the, yeah. He is. Secretary of health and human services, right. Okay. Thank you. So I'm also putting in the chat, protectmedicare.net, that's that website we were talking about. And on there, you can find all the links for those other like the petitions and stuff. But if you belong to an organization like community of Vermont elders or other senior groups, if you belong to advocacy groups like rights and democracy, if you belong to V-PURG or something, if you belong to organizations that work out for the public good, then you could also ask them what they're doing toward working on opposing these and stopping them. Any other questions or comments? Rebecca. Just a quick question. The Vermont council on aging the area offices, are they reaching out to Becerra and on board as well? So they have huge concerns about it. I was just speaking with someone there who said that they have had a 40% increase in complaints about Medicare Advantage because of the increase in marketing and that we are having more people in Vermont on Medicare Advantage now. We went from four plans a couple of years ago to eight this year. So there's like a doubling in the number of plans here. But she said that they're part of their funding actually comes from health and human services. And so if it's a current policy of health and human services, they cannot vocally oppose it because of their grant funding. But I mentioned something too, they're expanding use of... Mary Alice, your voice left us. You said they're expanding and then we lost you. Oh dear. So somebody's expanding something. Can you hear me? Oh, I heard that now. Now you're back. It's, I have a very bad internet connection, but that they're using home health and they're using SASH, we're getting all kinds of contacts in the home. And that's wonderful, but it's like they're using that to save money so that you don't go to see your doctor or see a provider who really can maybe help you. So home visits can actually be really wonderful. They can provide an actual visualization of what the person is living in. So if they're, for instance, handicap, what kinds of barriers do they have? So there are huge benefits to having a home visit. It makes it easier on the patient if they're in a lot of pain, if they're nauseated, you don't want somebody throwing up while they're trying to drive themselves to the hospital or something. So for instance, in France, they have like teams of people that are running around doing home visits all the time and it's not thought of as being like a detriment or anything. In the UK, they have people who are set aside every day out of their primary care providers. Most of them are scheduled to see patients and somebody is scheduled to go out and see people who are too sick to come in. You don't want them sitting in your waiting room and infecting other people or you don't want them throwing up in your office. So they pay home visits there. So there can be benefits that way. On the other hand, some of these organizations, these like direct contracting entities, will actually pay people to go in and do home visits not because it was convenient for the patient or helpful for the patient anyway, but so they can go and look over on for clues about ways that they could up code. Like, oh, you had forgotten to tell us that you're on a CPAP machine. Let's see if we can make anything out of that since I see that in your bedroom. So they're actually, they're paying people to look for ways to up code. They're spending healthcare providers time looking for that instead of looking for ways to improve your healthcare and give you a better quality of life and all. Yes, I'm 85 years old and I have a list a mile long of all the different things I have. Some of them are things I had when I was a child. Like I used to have ear infections. So now I think they think I'm hard of hearing. You know, how can they get away with that? Well, problem-oriented medical list is actually helpful for many things, but yeah, when you're taking things off of it purely to up code that's not good for patients. So thank you all so much for your time. I appreciate your concern that you came to hear about this and you can find more information at that protectmedicare.net. If you're interested in the May 23rd, does somebody have a link to throw in the chat here before we close out? I don't. Well, thank you so much to Orca for reporting this. I'll stay on for a minute and see if there are some things to pop in the chat for you all, but we'll wind up and thank you so much for your time and your attention. And I hope that you can help us in opposing this privatization of our highly effective and much beloved public health program Medicare. Thank you.