 Meeting of November 2nd, 2022 of the Green Mountain Care Board. Good afternoon. I'm Owen Foster. Thank you all for your patience. We had a little technical glitch. And so today's meeting, we will be receiving a presentation by the Green Mountain Care Board staff on the gather health. Budget submission. So first, I'll turn it over to the executive director, Ms. Barrett for the executive director's report. Thank you. Can you all hear me? Yes, okay, so I will be brief since I've done this once already, but I will direct folks to our public comment site on our Green Mountain Care Board website. We have several ongoing public comments. One is regarding one care Vermont and they will be presenting their budget to us next week. Staff will present on their analysis on December 7th instructions to provide public comment or on our website. In addition, gather health is open for their FY23 budget for public comment. We will hear more from our staff today on that timeline and how you can comment. I do want to alert folks that we did yesterday receive the FY, excuse me, the five year comprehensive 2023 to 2027 Vermont health information exchange strategic plan and connectivity criteria. For 2023. We will hear from the agency of human services and the Vermont information technology leaders on that plan on November 16th and we ask for public comments to be provided before the Green Mountain Care Board analysis and the potential vote from the board, which is tentatively scheduled December 7th or December 14th. We've also we will be posting this afternoon information on the extension for the all the current all pair model. We will also hear from Green Mountain Care Board staff on that extension on November 16th. We have a potential vote scheduled for November 28th. Last but not least, we would have an ongoing public comment on a next potential all pair model. And those comments that we received, we share with AHS and the governor's office as they are leading those negotiations. And I also wanted to draw attention to information on our website on premium tax credits that were enhanced and extended earlier this year by the feds and also remind everyone that open enrollment. Plans on the exchange are is open. So please check that out on our website. There are links as well as the diva website for the exchange and I will turn it back to you. Mr chair for a second time. Thank you very much. We had two meetings last week on October 24th and 26th and I'd like to take up the meeting minutes of October 24th 2022 is there a motion to approve the minutes. So moved. Second. Is there any board discussion? Those in favor of approval of the minutes of October 24th 2022, please say aye. Aye. Aye. Aye. That is four votes in favor of approval. Ms. Holmes abstained. I presume because she was not in attendance. Yes. Thank you. The minutes are approved. I'd like to take up the meeting minutes of October 26th. Is there a motion to approve the minutes? So moved. Second. Any board discussion? Those in favor of the approval of the minutes from October 26th 2022, please say aye. Aye. Aye. Aye. And there is unanimous approval of the minutes of October 26th. And with that we're going to hear from Marissa Melamed and Julia Bowles relating to the staff's review of the gather health budget submission. Ms. Melamed. Thank you, Mr. Chair and members of the board, members of the public. We're pleased to be back with you today for part two of the gather health budget review, which is the staff preliminary analysis and recommendations. The agenda for today, Julia, you can go to the next slide, is some brief background on Green Mountain Care Board Authority criteria and background on the ACO. This will be brief because we did hear about this previously from gatherers themselves. And then we will move to the staff review and staff recommendations, board questions and discussion, and time for public comment and the next steps in this process. So quick reminder, what we're talking about today is the board's authority to review the budget of ACOs operating in Vermont. In this case, gather health ACO is an ACO that is accepting payments and has an agreement with Medicare only, so they're subject to budget review, but not the board's certification review. They also do not at this time meet the threshold of 10,000 lives. And so the scope of the review is a little bit more at the discretion of the board, the standards and processes that the Green Mountain Care Board deems appropriate within the rule. And the board develops a guidance for Medicare only ACOs, which gather health has responded to, as well as some follow-up questions that we sent them specifically and today is the culmination of the review of the information that we have to date and our preliminary recommendations. On the next slide to review, what is the board approving here? It's under 18VSA 9382 and rule five, the Green Mountain Care Board shall review and approve or modify an ACOs budget. Also, as a reminder, the board has the ability to sort of designate the criteria that is relevant to the size and scope of the ACO in this category, but they are subject to any and all required reporting obligations under rule five. Next slide. And again, here are the outline of the criteria. So number one, any benchmarks established under section 5.402 of this rule, there are no benchmarks that have been established for ACOs in this criteria or gather specifically. So what we really are looking at is two, the criteria that the board deems appropriate to the ACO size and scope and we have proposed criteria, which we presented last week and is in this presentation as well. Also, number three, we consider the elements of the ACOs pay or specific programs and any applicable requirements of 18VSA 9551 or the Vermont All-Payer Accountable Care Organization model agreement. So we have some questions and data that pertains to our reporting requirements under the All-Payer model that are applicable. And then of course, number four, any other issues that are at the discretion of the board. Slide six, we went over this last week. I don't need to review them all again, but for your consideration, here are the, I believe it's nine total criteria that we determined are the most appropriate to the size and scope of this ACO. And so the findings that we are presenting are meant to address these criteria. So that's slide six and seven. You can go to slide eight. What this builds to is after the board votes on the budget to so to approve or approve with modifications, the Green Mountain Care Board will issue a written budget order that sets out the findings, conclusions and conditions of the ACO's budget review. So what we're going to do today is provide some recommendations which adopted by the board would become the conditions of the budget order. And again, this is an opportunity to discuss these recommendations or bring up any other issues or questions. There won't be a vote today. And I'm going to pass it onto Julia to continue with the timeline and the beginning of the analysis. Thanks, Julia. Great. And can I get a nod that people can hear me? Okay. Awesome. Wonderful. Thank you. Yep. So continuing from what Marissa just covered, we wanted to just remind everyone of the timeline. Hopefully last Monday doesn't feel too long ago when we heard from gather themselves at their hearing. We are here today in November already with our staff analysis. And as Marissa just said, the vote is potentially scheduled for November 16th. So today is just the analysis and discussion. And as Susan reminded folks at the beginning of this meeting, there is an open public comment period on gather's budget. We asked to receive comments by Friday, November 11th so that the board can have time to consider them ahead of the vote. And at this time, we have not received any written public comment on gather's submission. So getting a little more into the details here, we wanted to start with the big picture. So we are reviewing gather health, which is a Medicare only ACO. They are participating in the Medicare shared savings program, which they also provided a lot of detail about last week. And this program has been around for a decade now. And it is a large national program with almost 500 ACOs and covering 11 million beneficiaries. The agreement as we think about the Medicare shared savings program is between CMS, the payer, the ACO, which is gather health, and then providers who are contracting with the ACO. And as part of the program ACOs that sign up for the enhanced track of the Medicare shared savings program are signing up for a five-year agreement with CMS. And 2023 will be gather health first year participating in the program and operating as an ACO in general. And they are working with providers across six states, including Vermont. So a reminder about how this impacts beneficiaries and their experience as it pertains to this model. So beneficiaries that would be aligned to the ACO are still in traditional Medicare. So this means that being attributed to the ACO does not change anything about their access to their Medicare benefits, their out-of-pocket costs, their premiums, or their ability to use supplemental insurance. Again, because it's kind of an agreement between the providers, the ACO and Medicare, sort of a little more behind the scenes. And additionally, there are beneficiary rights in the program specifically that beneficiaries need to be notified and have the option to decline claims data sharing. And furthermore, because as a patient attributed to a provider in this program, beneficiaries may also have additional access to in-kind benefits, which we will detail later in this presentation. So this slide has details about and sort of a summary of the CMS monitoring of the SHODE savings program. There's a lot here, but these are some of the things we wanted to highlight that are sort of already being monitored at the federal level. This includes that ACOs must have a compliance plan with specific elements that are specified by CMS. The ACO must have a public website with information, including their name and contact information, as well as the ACO governing body information, SHODE savings and losses, and performance on quality measures once those are available. Additionally, the beneficiary notifications that I just mentioned, and CMS also has a broad ability to ask for information from the ACO as well as its participants. So with that as a backdrop, we've covered the scope of the GMCB's review and a bit about the federal oversight of this program. So now we are ready to dive into gather health specific information. So this slide just shows the sections of the guidance on that document that Marissa mentioned earlier. So we organized our review around the section. So kicking off with section one, this section has information about the ACO broadly, as well as its governing body. As I just mentioned, CMS dictates the requirements for the ACO's governing body and the members are listed on Gather Health's website. There are 12 members of their governing body, and two of them are clinicians from the participating provider in Vermont. There is currently one vacancy on the governing body, which is an ACO beneficiary, which gather will fill once the plan year starts. Of course, they can't find a beneficiary until they have begun. So at this time, we don't have any recommendations as it pertains to section one of the guidance. Moving on to section two, which is focused on the provider network. So as I mentioned, Gather has providers in six states and additionally has stated their intent to expand their provider network in Vermont in future years. And in our question about their network development strategy, they detailed that they are seeking to work with providers who are committed to lifestyle medicine and helping patients achieve their goals in a community. So to put this more into perspective and give you sort of the picture of the Vermont piece of their network, this slide shows their submission information across the top. So Gather Health has contracted with Springfield Medical Care Systems on Rostar Health, and there are 58 primary care providers in the network. From those providers, Gather is expecting nearly 5,000 attributed lives. And as you can see from the map in the bottom right hand corner, there are practice locations both in Vermont and New Hampshire. So of those 58 providers, 52 of them are primarily based in Vermont. And at this time, Gather does not currently have information about whether these attributed lives are Vermont residents or associated with Vermont practice sites. And again, that's kind of an element of the fact that this is a national ACO and we're taking the Vermont to make sure here. So in terms of the key points on this section, we wanted to just sort of summarize the information that we feel like we already have through this review, which is the network development information which we ask in the guidance every year. We have received a copy of their contract with providers and CMS also has monitoring in this area. And we also wanted to remind everyone more broadly that under GMCB rule 5.501, the ACO is required to keep certain records and report them to the board upon request. So for example, if the GMCB in the future needed to know the number of Vermont resident lives attributed to the ACO, that could fall under this. So given the extensive existing reporting, we do not have any recommendation pertaining to section two at this time. And with that, I'm going to pass it to Marissa to cover the next couple of sections. Great. Thanks, Julia. Section three is the payer program. The most basic here, the Medicare only program. So the risk model is sent by the Medicare shared savings program participation agreement with CMS. And it's based on which track the ACO chooses. So this is not a negotiation or Vermont specific model. The attribution is preliminary perspective assignment with retrospective reconciliation and voluntary alignment. Again, these are set by the program terms. On the next slide, we've shown this before, but this is a general fund flow of the Medicare shared savings program. So the so gather health agreement with the provider is determined to be exempt from public inspection under Vermont law. So we created this to be a general depiction of how MSSP funds can flow so that we have kind of an understanding about how the ACO model works. So I think we went through this a little bit before, but the three vertical boxes are the entities that are involved in the agreements of CMS, the ACO and participating providers. We have a box here for beneficiaries as well because of the optional in kind incentive program, which gather is participating in. And so if you start at the top, all fee for service claims payments continue to go directly from CMS to the provider with 100% fee for service. And then if you continue down to the payments from the ACO, so in the middle to the providers, the ACO can pay providers additional payments, which are determined by the ACO and part of their provider agreement. And these arrangements can vary by ACO in the MSSP program. And then as well, we have the depiction of the optional in kind incentive program. And again, this is an ACO designed program that they can take advantage of through these agreements. And this can include in kind incentives that are reasonably connected to beneficiary care or preventive items or services or advance the beneficiaries health care goals and are not covered by traditional Medicare. And then as well, you'll see the shaded boxes which are potential shared savings or shared losses that can flow between CMS and the ACO and the ACO and providers under their shared savings and shared loss agreements. Next slide is the ACO risk model. So under the Medicare shared savings program agreement, CMS provides standard risk model options. Gather Health shows the enhanced track, which is the highest risk level offered in the program. And that is shown in the third bullet. So in the enhanced track, shared savings are first dollar savings at a rate of 75% on the dollar if quality performance standard is met. And this is not to exceed 20% of the updated benchmark and shared losses. It's first dollar losses at a rate based on quality performance with minimum shared loss rate of 40% and maximum of 75. So that's variable. And it's not to exceed 15% of the updated benchmark. So there is a bit of an asymmetrical risk corridor here that they can have 20% on the upside and 15% on the downside. And again, these are wider risk corridors than we're used to seeing in some of our state-specific agreements. And then for risk mitigation, CMS requires ACOs to have a repayment mechanism and a financial guarantee set by CMS in order for ACOs to participate. Gather Health selected 0.5%. The options are between zero and 2%. CMS requires ACOs to have a repayment mechanism. And CMS truncates claims at the 99th percentile to cut off some of the volatility. So again, these are sort of standard options that the ACO can choose from. Section 3 to sum up. So our key points here is that the payer program arrangements are set by Medicare in the participation agreement. As a new ACO in 2023, Gather Health first shared savings and loss information will be available from CMS in the second half of 24. So they have to go through a full performance year and then have the results calculated and those will be available in 24. And so that brings us to our first recommendation, which is that Gather Health provides to Green Mountain Care Board its shared savings and losses, which is already required to be publicly reported. But we would like them to be reported to us specifically and segmented for Vermont as feeable. So moving on to Section 4, which is the budget and finances. So then this again, this is a depiction of what they showed to us last week during their hearing. The slides here are projections that are based on assumed shared savings. So this is totally theoretical, assuming a 5% savings rate. It's just to show, it's just to give you an example about how the math works out. So the projected or could work out. The projected Vermont benchmark is $49.5 million, which is based on the roughly 5,000 beneficiaries at 9,900 per member per year spending per beneficiary, which comes from publicly derived Medicare data. Medicare payments to Vermont providers at assuming 5% shared savings would mean a little over 47 million. So that's, you know, making an assumption that the total spending is 5% below the benchmark. So then from there, the projected in-kind incentives and shared savings with Vermont providers is about $1.5 million. The estimated ACO care management payments are half a million. And then the, so the estimated operating expenses prorated for Vermont are $225,000 with the estimated net shared savings retained by the ACO at $255,000. So again, these are our theoretical budget assumptions based on theoretical results. So for section four, budget and finances. So the ACO is making payments to Vermont providers and paying for in-kind incentives for Vermont beneficiaries. The budget numbers in the previous slides are estimates that assume a 5% shared savings. And the actual shared savings shared loss results will not be known until mid-24. So that brings us to our second recommendation, which is that Gather Health provides an updated version of their Vermont financial summary with actuals, including a breakout for in-kind incentive spending. And the Greenmont Care Board staff will develop a template and set an appropriate deadline for when we'd like to see actuals if we want, interim or final. And that is to be determined or could be delegated to staff. I'm going to pass it over or back to Julia to go over section five and the model of care. Yeah, thank you. So section five is about the ACO's model of care. And as a reminder, these are some of the applicable criteria that were summarized in the slides at the beginning. And additionally, I think we've hit this nail on the head many times, but Gather Health is a new ACO. So also, as we think about this, 2023 will be their beginning of testing this model of care. So that's just a helpful framework to keep in mind. So their focus is on addressing chronic diseases through lifestyle medicine interventions. Within this, this includes a focus on transitions of care and using available data sources to support providers in this work. Additionally, they support beneficiaries health needs through those in-kind incentives that help beneficiaries manage and prevent chronic conditions. Gather is also supportive of providers engaging in local programs that have shared goals, such as the blueprint for health. And they are working to build community through the Gather Health platform. And to provide a little more information on that, we had asked them follow-up questions and receive responses last Friday, 10-28. So this is some of the information from their responses. So in describing the Gather Health platform, they said that patients interact with the Gather Health platform by enrolling, then engaging in curated interactions between them and others on the platform. The platform also serves as a main way to participate in the ACO's chronic disease care management program. Beneficiaries will work with Gather Health or their providers if they do not have or cannot navigate digital access. And the community is intentionally designed to focus on preventing and reversing chronic diseases by building disease-specific evidence-based community modules for beneficiaries to interact with and meet. So the key points from this section, again, are that Gather Health is a new ACO and they will be testing their unique care model beginning in January of 2023. And their care model includes a platform that beneficiaries will be using and interacting with. So based on that information, the staff had three recommendations pertaining to Section 5. The first being that Gather Health provides to the GMCB its quality reporting segmented for Vermont if possible with appropriate restrictions to protect patient confidentiality. And as a reminder, this would be the quality reporting that would not be available until the middle of 2024 due to needing to complete the performance here and then some time for the run-out. Our second recommendation on this section is for Gather Health to provide a copy of the terms and conditions given to beneficiaries upon signing up for the Gather Health platform as well as any other marketing or informational material shared with beneficiaries. And if the intended use of beneficiary data changes from what Gather Health presented to the GMCB on 10.24.22, which was their hearing, then Gather Health must report any changes to the GMCB. And finally, our third recommendation on this section is for Gather Health to provide a bi-annual update with the first report being submitted in conjunction with their fiscal year 24 budget, which would be October 1st of 2023. And that report would be about how Gather Health care model is working in Vermont, including the number of Vermont attributed patients who are registered to the Gather Health platform and any unique Vermont challenges. And the report template could be developed by GMCB staff. So there's one section left and this goes back to thinking about how this program relates to the all-payer model. So section six has a number of different tables that help us compare this ACO program, the Medicare Shared Savings Program, and its elements to Vermont's all-payer model. So I'll walk through some of the findings here. So for scale, the staff are still reviewing Gather Health information and the scale qualifying criteria. The second table in that section is showing that the Medicare Shared Savings Program arrangements are a Category 3B on the HCP land categories, which is a framework to help classify alternative payment models in a more standardized way. The financial targets are well aligned between the all-payer model and the Medicare Shared Savings Program, and finally the quality targets in the Shared Savings Program are a bit narrower than the all- payer model, but there is a lot of overlap, especially as it relates to clinical depression, hypertension, and diabetes. So at this time, the staff do not have any recommendations on this section. So in closing, we wanted to reiterate the special public comment period for Gather Health budget. The public can submit comments through November 11th in order to allow time to be considered ahead of the board's potential vote on November 16th, and more information on this can be found on the GMCB's website. The remaining agenda for today is board questions and discussions, HCA comments, and then public comments. So I'm going to go to the next slide, which I'm happy to leave on the screen, which has a summary of the recommendations, which we thought would be helpful potentially for board discussion. So with that, I will turn it back to you, Mr. Chair. Thank you both very, very much. You guys have done great work on this. I appreciate it. With that, I'll turn it over to my fellow board members for any questions or comments they may have. Hearing none, I have two quick ones. I think it was slides 23 and 24, section four, related to financial backing. I found that their business model description was a bit opaque, and it gave me some concerns regarding the financial backing and wherewithal. Before voting, I think it would be beneficial for me to understand and see the corporate organizational chart and if there are any related entities and where the gather health platform sits in that corporate structure and also if there's any commingling of funds or sharing of data or use of data with other entities that may or may not be related. The only other comment or question I had was relating to recommendation number four, whether or not we can have a certification signed by executives indicating whether or not there's been any changes in how they're using data on behalf of any third parties and or selling identified or de-identified data. I think this is important for monitors to know. I appreciate their representations. Things can, of course, change in a business's life, and if they do, I think everyone has a right to understand it as it can impact the bottom lines of the ACO. Thank you, and with that, I'll see if there's any other board questions or comments. Yeah. Oh, I'm sorry. I couldn't get to my mute button. Finally, actually, my mouse was not working, so I think I'm good now. Can I ask two quick questions then? Please, of course. Thank you. I'm just wondering on recommendation two, what is the frequency with which the staff's recommending updating their version of with actuals? I think I heard you say at an interim basis or at year end that I'm wondering if you're thinking at midpoint and then at the year end or just the year end? I do not have a recommendation at this time, which is why we said staff to develop. I'd like to discuss with gather to see when that might make sense, like when we would have some meaningful results. So I'd like to defer sort of the frequency for now, but I'll see if I can get an answer for that prior to the vote if possible. Okay. No, that's great. And then I'm just going to add to recommendation five. I think it would be helpful to understand not only the number of Vermont attributed patients that are registered to the platform, but some measure of their usage, their, you know, the frequency of their engagement on that platform. I think it's, you know, it'll be interesting lessons learned on how this, you know, new model of care management works to understand really how fully engaged or how frequently people are actually on the platform to get a sense of how well it's working. So those are my two comments. Thank you. If I could just piggyback onto that. The thing that comes to mind from Jess's comment, if we could, if we could understand the total number of visits to their platform and unique visitors, that would be helpful for us to understand the amount of engagement and how they may overcome the challenges of our geography and us, Vermonters, and willingness to participate. If I may respond to those two comments, this is really helpful and exactly the kind of thing we're looking for in this discussion because as you can see how it's written here, we sort of defer the development of the template because we didn't have enough time to figure out exactly what that would look like. So these suggestions made here are very helpful in helping us develop that. And I believe we can check with legal, but I think we can either try to hash it out by the time you vote or I believe in the past we have sort of delegated template development in the budget order to a staff process. And so we can figure out the best way to do that just to make sure that we get it right instead of rushed. Thank you. Great work. Dr. Merman, I see you have your light on here. Go ahead. I still would like to learn more about these curated interactions through the template and I'm trying to figure out what it is that we could ask them to gain better insight as to how the curation occurs. I think that if we're having patients engaged in a clinical environment that's I mean they use the word curated that's different than typical clinical environments or even non-clinical environments I feel that there should be some reporting of that process. So maybe I might want to work with you a little bit more on crafting a recommendation or something to ask gather to report on with regards to that. I'm still trying to figure out how to specifically ask that. That's great. I think again we can work those thoughts into recommendation five reporting but that's exactly what we're sort of trying to get at is a better understanding. So that's why we made that recommendation. Wonderful. And if there are no other board questions or comments I will turn it over to the health care advocate. Thanks so much for your foster. I just want to start off by thanking board staff for their presentation and give our support for the recommendations that Marissa and Julia outlined today. Also want to support your comment chair Foster regarding requesting more information about the corporate structure. I think it was also well I know it was feels opaque to us to a certain degree particularly around how much the platform is financed from within and under what terms. When we have the HCA look at and hear about issues facing Vermonters what we see is a crisis of affordability access and quality. And I know we're not alone in that perspective. So if we look at gather's approach and mission from that lens based on what we've seen and learned from the presentation and the board's review we're skeptical that their for profit data platform and application meaningfully addresses those issues for Vermonters. There's not a strong evidence base for health care IT startups like this moving the needle in these areas of need for the public. And if anything there's some emerging evidence that they increase overall costs. So with that public interest in mind and the knowledge that the board can't deny gather health stability to operate Vermont we recommend that they exercise that you exercise regulatory oversight and clear reporting requirements for gather. And we think that this oversight is important and appropriate to ensure that gather health promise benefits are actually realized. Thanks. Thank you very much for that input. We appreciate it. At this point if there's nothing further from the health care advocate I will turn it over to public comment. Please use the hand function. I myself have no clue how to do that. So I'm hopeful you do. And I'll call on people in the order in which their hand is raised and please identify yourself for the record. And the first hand I see is Walter Carpenter. Walter how are you? Please go ahead. Oh and I'm hanging in there for an old man hold health care activist. I'm Walter Carpenter health care activist from Montpelier. And I'm just I thank all in for his comments about the corporate structure and I thank the health care advocate for their comments and the staff of the GMC or Melissa and some company for their presentation. I'm just in their outlining of their issues about gather. And I agree with most of the comments that gather should be strictly monitored. Is gather a DCE direct contracting entity? I can answer that. Gather health is not a direct contracting or ACO reach entity. They are participating in Medicare's sort of flagship shared savings program which has been in operation since since 2012. So it's it's not operating under the the DCE model which has been sunset and is re emerging as the ACO reach model in 23 of which we do not have any ACOs participating in that model in Vermont for 23. And who are the shared savings going to? And then on their platform Tom raised a good point and I think a person with a serious illness is going not going to have much time to engage on a platform with a whole bunch of steps that you have to click through and procedures and bureaucratic hurdles. I know because I've been through them before. Thank you very much, Walter. Next I see a hand raised Dale Hackett. Mr. Hackett, the floor is yours. Thank you. Could you clarify first, did I hear it said that this is for profit? Gather health is in LLC. So yes, it would be a for profit entity. Blue Cross, Blue Shield, MVP, our hospitals, CMS, are they for profit? Thank you for the question, Mr. Hackett. I think that I don't have, I think I know the answer, but I think you can look up 501C3 status on public filings. If you'd like generally hospitals obviously government entities, etc, are generally not for profit. So my comment would simply be that while I haven't heard all the presentations, those conflict and scheduling for me, I couldn't be there. I would have concerns about where this is going and the ideology actually being in conflict. And I think others have already said that in terms of how it's really going to serve the patient. We'll see. But I would strongly suspect that it's probably not going to be the cheapest option. But maybe somehow it's more efficient if it does away with various gatekeeping or something like that, if it's streamlines or services, but then who benefits from the streamlining? Or their workforce shortages and so forth, or it's still be concerned about how fast services could be delivered, or if there's even a workforce to deliver to services, the ACO is looking to deliver. That's it. Thank you very much for sharing those thoughts, Mr. Hackett. Thank you for letting me. Of course. Are there any other public comments? Great. Marissa and Julia, thank you very, very much for your time and your effort on this. I know it was a lot of work and we appreciate it very, very much. It's a great job. With that, is there any old business to come before the board? Any new business to come before the board? And is there a motion to adjourn? So moved. Second. And all in favor, please say aye. Aye. Motion carries unanimously and we are adjourned. Thank you, everyone.