 We're going to get started anyways. So at this point in time, I'm going to appoint Michael Barber as the hearing officer. And Michael will run the hearing from here. Thank you, Mr. Chair. So good morning, as the Chair said. My name is Michael Barber. I've been appointed as the hearing officer for today's hearing. The purpose of this hearing is to take evidence, argument on the 2020 Vermont Health Connect rate filing submitted by UVT Health Plan Inc. The docket number in this case is GMCB-005-19RR. The Green Mountain Care Board has jurisdiction over this matter pursuant to the Title 18 of the Vermont Statute Annotated Section 9375-86, as well as Title VIII, Section 4062-8. Representing the Carrier, MBP, our Carey Carnegie, and Ryan Long of the Law Firm, Colonel Piper Egelson-Cramer, PC. Representing the Office of the Health Care Advocate, R.J. Hangoff, Kyrie Piper, and Eric Schulteis. I also want to recognize the Board's Associate General Counsel, Amber Ann Averjaley, who will be leading the examination of the Board's actuaries, Lewis and Ellis. We are recording today's proceedings. We have the Board here as well. We'll transcribe the proceedings, and we will provide the parties with the transcripts as soon as we receive the questions. I think I recognize most of the cases in the audience, but if we have members of the public here today, welcome. We will be taking public comment at the close of the proceedings today. There is a sign-up sheet, or there should be a sign-up sheet outside the room. We'd like to take advantage of that opportunity. However, I can't say when we will get to the public comment portion of the meeting. And if you don't want to sit through several hours of testimony from actuaries to make a comment, we are having a meeting tomorrow from 4.30 to 6.30 PM at the Montalier City Hall, and that meeting will be dedicated exclusively to hearing from the public. Additionally, you can always submit written comments to the Board via its website or by regular mail. And finally, you can call our offices to make a comment if you like. We will be accepting public comments July 25th. Before we begin, I want to remind the parties that and the Board that some of the materials the MVP has submitted in this filing are confidential, and you should exercise caution in discussing anything that has been marked confidential in these binders because they can't be discussed in a public setting. At this point, I think I'd like to square any of the witnesses. So, absent in any rebuttal witnesses, we expect to hear from Matt Lombardo, Mike Fisher, Jacqueline Lee, and Jesse Luce here, who I don't see in the audience. So, if I called your name, please stand and raise your right hand. Do you square or burn the testimony you will give in this matter? Will be the truth, the whole truth, or nothing but the truth? Thank you for maybe seeing it. Now that you've sworn in the witnesses, we have a binder of exhibits that the parties have stipulated to. I understand the binder contains 12 MVP exhibits, which are marked one through 12, and 16 exhibits from the Office of the Healthcare Advocate, which are marked 13 through 28. Mr. Connor, V. Mr. Engel, am I correct that the parties have stipulated to the admissibility of those documents? Yeah, that's correct. Okay, then at this point, I'm going to admit those documents in the evidence. Does either party have anything to discuss before we get to opening the statements? I'd like to know who's there. Thank you very much. As you've already indicated, my name is Gary Carony, and I represent MVP again this year. This is a 2023 filing. I have to be my associate by long, and as you've already indicated, Matt Farr is here, who's the senior leader of actual services from MVP, and we're here today as well. MVP's original major is great filing, so I didn't increase it to 90.4% based on a multitude of issues. The evidence will show that L&E is recommended to increase to 2.5% again based on a multitude of issues. The evidence will show that MVP agrees with all of L&E's recommendations. You will hear evidence also based on recent possible pledging proposals. MVP is increasing its proposed rate to 11%. You do not yet know L&E's position on an aggressive possible pledging information, but we should hear more about that today. Consumers, the totality of evidence will show that all the expert actuaries in this case agree on virtually everything, agree on virtually all of MVP's proposed 11% increase. The HCA is not offering expert actuaries as it has in prior years, so no other expert actuaries will be testifying today in support of some substantially different, lower, or higher degree. As a matter of law, decision by the board must be based on evidence, not on speculation of non-expert witnesses. The proposed premium should be found if you sufficiently pay for the services and products covered. This should be actually sound and statutorily added. It's important to recognize that in a relationship of all statutory criteria, because of this interrelationship, although it is true that the board is not limited to actuarial considerations, in exercising its discretion, it should consider whether a change of rate based on the non-actuarial ground will run file, the actuarial data. Said another way, reductions should not ignore the math or ignore the actuarial evidence on what is needed for statutorily added of rate. A non-actuarial change in the rate still impacts the actuarial soundness of rate funding, it's all interrelated. MVP recognizes the difficult choices the board has to make each year in balancing, in balancing statutory criteria. We respectfully submit that considering other statutory criteria, such as affordability, in exercising its discretion, the board should consider the rate within what is actuarially sound and reasonable and statutorily adequate. The board should endeavor to avoid unintended consequence of a rate decision that's not actuarially sound or reasonable. Actuaries are very zen-like in calculating rate increases. Let me give you an analogy. If you walk on most any trail of the line, you're gonna come upon at some point a stack of all the stones that are stacked by somebody but then somehow they're balanced. The rocks are stacked on top of each other to find just the right balance to stand and not fall over. Each stone is like a statutory criteria and the evidence will show that MVP and your actuaries at L.D. have found just the right balance to meet all the statutory criteria. You might be able to make a small adjustment to take a stone near the top and still maintain the balance. But if you pull a large stone from the middle of that pile, they all come from L.D. The rates would no longer be adequate. So considering the evidence, the board needs to keep an eye on all of the other related statutory factors on the stack of statutory stones to maintain the balance. It's very nice. Do you have anything to add to that? Yes, sir. Thank you very much. It's no secret to the board that Vermont is unique in several ways. One of the ways it's unique is in the standard and the process that we go through in this procedure. In all other states, there is no big hearing process like this. There are some states where there's prior approval where the company has to file its rates with the insurance department and those rates can't take effect unless the insurance department approves them. But there is no hearing process like this. So this is the most expensive hearing process in the country. Vermont is also unique and this is even more important in the standard that you all must use to determine whether or not a rate should be approved. In other states, the standard is, is the rate excessive, inadequate, or unfairly discriminatory? That's the sole standard. And that's what actuary is determined. You have a much tougher job than any regulator in any other state because you not only have to determine whether or not the rate is excessive or inadequate or unfairly discriminatory, which is what the actuary's expertise is confined to, but also you've got to determine whether the rate is affordable, whether it promotes quality of care. Those are things that the actuary, no actuary, whether it's the MVP actuary or L&E or anyone else, those are things that are just not within an actuary's competence. In addition, although we use the term actuarial science, what actuaries do is not a science. The one thing you know about whatever the actuary's projection of the rate increase should be is that it's almost certain to be wrong. There's a big range within which people can disagree as to whether or not a rate increase is likely to be excessive and actuary or unfairly discriminatory. MVP, sorry, L&E to its credit notes that there are many different methodologies that can be used and they pick one MVP that's more. MVP also, and MVP to its credit, acknowledges that in the past, last year, for example, the assumptions, some of the assumptions they made and some of the assumptions L&E made were wrong. So all of this is known, it's certainly not a reason to not have this theory. What the actuaries have to say is important. It's necessary, but it's not sufficient. So Mr. Kern, all your first comments? We'll call Matt and Martin over the next, hopefully not multiple hours, but over the next time. Please respond towards the board so they can hear you okay. All right? So would you state your name for the record? Matthew LaBarda. And Matt, who's your employer? MVP HealthCare. And I understand the filing was made by MVP HealthPlan Inc. What is MVP HealthPlan Inc. or how is it related to MVP HealthCare? It's MVP's HMO subsidiary. It's the Lee-Lem Steeves non-profit HMO company that falls under the umbrella company of MVP HealthCare. And what is your position at MVP? Senior leader of actuarial services. And are you a member of any professional associations? Yes, I'm a fellow in the Society of Actuaries, I'm a member of the American Cadence Actuaries. And how long have you been employed in the health insurance industry? Around 14 years. And what do your job do as a senior leader of actuarial services? In addition to overseeing premium rate setting, I'm also responsible for reserving our RIMR, financial forecasting, financial competitive intelligence, and also value-based contracting or risk-sharing arrangements with provider groups. Matt, I would refer you to the binder in front of you that asked you to open it. You'll find a stipulated exhibit list in front of the binder. Do you see that? Yes. I just want to walk through this and just identify some things. Starting with exhibits one through eight, you'll see exhibit one is the original rate filing. Correct? Correct. And then exhibit two is the amended rate filing. Correct. And then after that, through eight are a series of responses by MVP to questions from dream health care. Correct? Correct. And then exhibit nine, that's L&E's July 16th actuarial opinion. Correct? Correct. Okay. And then exhibit 10 is DFR's Solvency Analysis Letter? Correct. Correct. Exhibit 11 is an MVP's filing on July 11th of a non-standard goal design. Correct? Correct. And then finally, exhibit 12 is your CB. Correct? Correct. And the balance of the exhibits are HCA exhibits. Correct? Yes. Correct. And you've reviewed all these exhibits and adopt them as your testimony with exception, obviously, the DFR exhibit and the L&E exhibit. Correct? Correct. But you reviewed those two exhibits and are familiar with them? Correct. Correct. And then next map, I just ask you just to open up the first exhibit to any page and look on the bottom, right hand corner, and you'll see a darker number. You see that? Yes. So these are the page numbers that we put on all the exhibits. And I'd ask you as we talk, I'll refer to those pages if you could do the same as well. Okay? Okay. So let's start with an explanation at a high level of the rating increases. Matt, you'll go to exhibit two, please. Page 15. Okay, Matt. Can you see under, there's three words, fielding, request to change in prior value. Can you see that? Yes. So would you tell the board what, oh, I'm sorry, and then go down to the bottom of the exhibit by the number 15, do you see that date over to the left? Yes. What's that date? May 23rd, 2019. Okay, so this is the amended filing by the MVP on that date, correct? Correct. So going back up to where I was referencing, can you tell the board what the original filing rate increase request was and how it's changed in reference to those numbers? Yes, when we initially submit rates on May 10th, we proposed an average rate increase of 9.3%. Upon reviewing the interrogatory for Melanie, we identified a discrepancy that we used the proposed hospital budgets for 2019 rather than the approved hospital budgets. And we made that change on May 23rd. So the result was a decrease in the overall proposed rate increase of 8.45%. Thank you. Would you go to exhibit nine? Exhibit nine. This is the L&E report dated July 16th, correct? Correct. This is their amended report, correct? Correct. And would you go please to page 15 of that exhibit, page 15? Do you see that there's seven bullets on that page and there's four recommendations? Yes. And these show some decreases and some decreases to the rate as proposed by Melanie, correct? That's correct. And would you read the last sentence please on the page? After the modifications, the anticipated overall rate increase will increase from 9.4% to approximately 10.5%. And do you agree with that increase after reviewing Melanie's report? Based on the seven bullets, yes, I agree with that. And Matt, as I understand it, MVP received some additional possible budget proposals on July the 16th. Is that correct? That's correct. And did MVP make any adjustments to the proposed rate above this 10.5% as a result of that hospital budget proposal information? Although we didn't submit an amendment, we did run through the calculations on our own and when we updated our trend assumptions to reflect the proposed hospital budgets over release on July 16th, the 10.5% increase changed to 11.0%. So the rate increase that MVP is proposing as you see for today is 11%, is that correct? That's correct. And do you know what Melanie's position is on moving from there, 10.5 to the 11th? I do not. We'll go through this in greater detail on the hospital budgets. I'd like to go back to Exhibit 2, please, which is the amended rate filing. Walk through it on a few issues. 15, that's the phase we were at before. And you see where there's references to maximum percent change and minimum percent change. You see that? Yes. Would you please explain the change in those numbers from what we originally filed to the amended file? Yeah, the original range was 5% to 23.7%. The requested change column represents 4.1% to 22.6% for an average of 8.5%. I will caveat that since we submitted the amended filing, DFR has come back and asked us to amend a plan design. That was the plan design that was receiving the 22.6% increase. So that figure is actually gonna go down in math to something about, you know, from the ballpark of the 10% less. Thank you. And if you would go just down below there, there's a couple of, I guess it's columns. It's this way, I'm not sure. But you see where it says product, product name and so on, and it says number of recovered lives. You see that? Yes. And there's two references to the number of recovered lives, one above and one below. Yes. Can you explain those, please? The Vermont Health Connect Market is an merged market of individual policyholders and small group policyholders. In the individual market, MBP has 14,491 members or people covered. In the small group market, 16,396 members. Thank you. Matt, would you please go to page 22 of executive two? Is this the actual memorandum that explains the refile? Yes. Matt, if you would please go to the fourth paragraph under market slash benefits, let me know when you're there. Okay, I'm there. And the first sentence says all essential health benefits are covered. Can you see that? Yes. Can you explain that? One of the aspects of the Affordable Care Act was to ensure that adequate services were being rendered or covered under insurance policies that were ACA compliant. That list of benefits is called the essential health benefits. The federal government sets the floor for the minimum that can be covered and then every state has the ability to actually define what the essential health benefits are. So all of the benefit plans included in this filing are ACA compliant and cover all the essential health benefits in the state of Vermont. Thank you. And Matt, in the next paragraph, it starts with the non-standard plans. You see that paragraph? Yes. Can you explain how non-standard plans deal with this EHB? Yeah, non-standard plans also have to cover EHBs. So I'll go back. There's two types of plans being offered, standard plans and non-standard plans. Standard plans provide consumers with enabler-saddles shopping experience between carriers. And then non-standard plans cover, give the carriers the ability to offer something a little different, maybe a different cost-sharing elements like deductibles or co-pays, or you can offer additional benefits. In this case, MVP is offering a wellness benefit and are non-standard products that will cover up to $600 of reimbursement to policyholders that meets our criteria. Thank you. And Matt, would you go to the last paragraph on the page 22, and you'll see there's a reference to policyholders, subscribers, and members. Would you please describe the goal and the differences between those three categories and the number for the reference? Sure, I'll just read the sentence first. The book of business affected by this refiling is 11,696 policyholders, 20,156 subscribers, 30,887 members based on February 2019 membership. So in the individual market, policyholder is the contract holder, which we'll talk about more in the subscriber number. And then in the small group market, the employer is the policyholder. We offer single, double parent-child and family contracts. In the case of parent-child contract, for example, the adult holding the pop that holds contracts is considered the subscriber, and then the children plus the contract holder are all members. So members are people, subscribers are generally the person that is the zero, zero subscriber member ID on the planet. Great, Matt, we'll go to page 23, please. And you see in the second to last paragraph, which makes reference to the CSR subsidy program. Yes. That's something that you consider to be this amended file, correct? Correct. Would you please explain the CSR subsidy program? The CSR subsidy program was a feature of the ACA to help policyholders in the individual market that met certain income restrictions to help alleviate some of the pressure of cost sharing. So cost sharing being deductible to how insurance are co-pays. The federal government, plus there's an additional subsidy from the CSR program, were funding, it was funding the CSR program. The CSR program is still funding their portion of the CSR program, but the federal government stopped funding the program in October of 2017, and it's still not funded today. Thank you. Matt, would you go to page 26, please? And you see in the second to last paragraph, there's a reference to Y-19 adjustment for association health plans, can you see that? Yes. So association health plans were considered in this rate pipeline, correct? Correct. Would you please go to exhibit six, exhibit six. This is a response to a projection question by Elleny, so it's a response by MVP to a question from Elleny, correct? Correct. And if you reference number two, you see where it makes reference to the AHP market? Yes. So would you please explain what was happening with the associated health plans this year and how MVP addressed it? Beginning in 2019, associations could band together, smaller, they're smaller member groups and purchase non-Vermand health connect policies. MVP did not offer any of those policies in 2019, and based on our analysis, we estimate that approximately 20% of the 4,869 members that left the exchange market to go to association health plans were from MVP. We analyzed the morbidity, the historical claim costs with risk or adjustments for the population that left MVP versus who remained, and we found that generally speaking, that the population that left was much healthier. Now since then, on June 13th, 2019, DFR Bolton 205 declared that in 2020, association health plans will not be offered in Vermont. As a result, MVP is retracting the adjustment, which was on light, I don't recall which line I know, but we are retracting the adjustment, which was worth close to one percent. And that's reflected in the 11% we're seeking today, correct? Correct. I know I'm having to shuffle back and forth. Would you mind going back to exhibit two please, page 31. Down the last heading on the bottom is general administrative expense load including QI component, do you see that? Yes. And there's a reference to 42 PMPM in the first sentence. Do you see that? Yes. Would you please explain what that is? 42 dollars PMPMPMPM is per member per month. The proposed rates included in this filing assume that administrative costs such as overhead, maintain claims operating systems and so on and so forth will be approximately 42 dollars per member per month. And you've reviewed L&E's filing, correct? Correct. And did L&E find the administrative expense load in this 42 PMPM number reasonable and appropriate? Yes. If we talk more about that later, let's go to page 32 please. And you see at the top it says contribution to reserve risk charge? Yes. What is MVP proposing for a CTR this year? 1.5%. And what did MVP propose last year? 2%. And what did the board approve last year? 1.5%. And just above that you see there's a reference to bad debt expense? Yes. So last year what member used to ask you about bad debt expense, so I thought we could touch on that briefly now. What is bad debt expense? Bad debt is the risk of a policy holder not paying premium. The way that we develop a rate is that we start with claims and then project them forward to arrive at our claim projection for the projection year of 2020 in this case. There are instances where policy holders aren't actually paying premium and we are still covering claims for a time period even though we haven't collected premium for them. So in our redevelopment there's no contemplation of a policy holder not paying premium. And this adjustment which is based on historical averages, it accounts for the fact that we are paying claims yet we're not collecting premiums for everyone. And when you say this adjustment is that the 0.4%? Correct. And that's based at least in far upon prior years except by the historical data. Yes. Why is the bad debt number, why is that a separate line in the rate amount, separate from CTR? It's a separate charge. It's separate and distinct from contributions reserves or any other portion of the rate build up. CTR is based on monies for claims and the other things you identify. And this is based on the bad debt expenses based on people not paying their premiums. Is that right? That's right. Having those items separate, does that actually sound? Yes. Matt would you turn it please to exhibit the letter. July 11th, 2019 letter from MVP, correct? That's correct. You signed it correct? Yes. And there's a reference in the second paragraph of the Gold II non-standard plan. Can you see that? Yes. So would you please explain what the purpose of this filing is? After our submission, DFR upon review of a modification to the non-standard Gold II plan, found that it was out of compliance with CMS's regulation of uniform modification of coverage. As a result, we are going back and modifying our plan design to be much more similar to the plan that is being offered in 2019. The changes that we were offering were to try to remove the deductible from the plan. We have an $850 deductible place today. MVP's proposed plan design was offered a zero deductible plan. Because the change was so large, it fell outside the range of uniform modification coverage, which is resulting in us having to refile this plan design. And Matt, this is something that was required by DFR, correct? That's correct. And would you please read the first sentence of the last paragraph? The first document confirms that the updated plan design fits within the Gold Medal level and satisfies federal AV requirements. You agree with that and both that, right? Yes. And then let's go down to the second to last sentence that starts consistent with. Would you please read that sentence? Consistent with the calculation performed by L and E in the actual memorandum dated July 9th, 2019, the impact of this plan design change on the contract-weighted rate increase is a decrease, approximately 0.2%. Okay, so the Gold II non-standard plan modification to design resulted in an overall rate decrease of 0.2%, is that correct? On the overall contract-weighted rate increase, yes. The actual plan change, Gold II non-standard, is much larger. And would you read that last sentence, please, on that issue? The Gold II non-standard rate increase for 2020 is now proposed to be 10.4% reduced from the 22.6% increase in the amended filing. Okay, I'd like to pivot to L and E recommendations this year. Would you go to exhibit nine, on stage 15, please? Look at this briefly earlier. You can see there's seven bullets regarding recommendations. Do you see those? Yes. I want to go through each one, but overall, is MVP agree with L and E's recommendations? Yes. Let's start with the first one. Cost trend from 2018 to 2020, do you see that? Yes. What is the cost trend? Cost trend is just general inflation. So, if a service costs $100 in 2018, and we anticipate the cost to be $110 in 2020, then that represents the 10% trend over both years. And there's a reference to the hospital budgets in that area, correct? Correct. So our hospital cost part of the cost trend? Yes. And I believe he testified this earlier, but MVP, it's original filing, used original filing rather than approved hospital budgets. Is that right? Yes. And so this first bullet, what does it result in terms of the change? It's a reduction of 0.9%. It's the same 0.9% that we discussed the impact of the proposed filing to the amended file. Thank you. So we agree with this recommendation, correct? Yes, correct. Let's go to the second bullet, please. Cost trend from 2019 to 2020. Do you see that? Yes. Would you read the first sentence, please? If updated information regarding unit cost trends are known at the time of the Board Order, L&E recommends updating the assumed unit cost trends in the 2020 premium rate calculations. And do you agree with that recommendation? Yes. And are there challenges considering unit cost trends leading to hospital budgets here in the line? The timeline of the hospital budget approval isn't aligned with what rates are proposed or decisions are rendered. So we submitted our initial rate filing on May 10th. We did not receive the final proposed hospital budgets until July 16th. A rate decision will be rendered sometime in early to mid August. And we don't anticipate to receive approved hospital budgets until sometime after that. So that's a challenge. Yes. And in April or thereabouts this year, the Board made some rate changes for several hospital facilities, is that right? That's correct. There were adjustments made from the approved hospital budgets for two hospitals after the initial decision rendered So that was not contemplated at the time of the hospital budget approval, is that correct? Correct. And all that poses a second challenge, correct? Correct. And then third, are there facilities that are not under the Green Mountain Care Board's jurisdiction? Yes, MVPs, benefits and products offered in the filing cover a nationwide network of providers and facilities and pharmacies. So MVP contracts directly with most facilities in upstate New York and providers. We also contract with Dr. Pitchcock in New Hampshire. And after that, we rely on a national carrier to use their network so that if a Vermonner is vacationing in Arizona or California and they need medical care, they can access a provider facility with as a network provider no additional cost sharing above and beyond what's in their benefits if they saw a provider rid of the street. Thank you, Matt. Would you please go in that exhibit, go to page five please? Page five? Do you see that there's a bullet on the bottom? Do you see that? Yes. Would you read that please? Approximately 40% of medical services are provided by hospitals not subject to the Green Mountain Care Board hospital budgeting process. Now, originally in L&E's first filing, did they have a different percentage there? Yes. And what was that percentage? Believe it was 55%. So they clarified that error correct with this filing on July 16th, correct? Yes, correct. And by making that change, does that change your agreement with L&E on their ultimate conclusions? It does not impact the proposed rate change. And then in that visible blue box next to the bullet, see where it says GMC, the hospital budget review. Yes. And there's a number two there. Would you read that please? A trend of 5.5% for other medical facilities and providers that are not subject to the hospital budget review. Does this figure change based on L&E making the one change to 40 to 55%? It does not. Now, you referenced earlier on hospital budget totals on the came in, the last one came in on Tuesday, July 16th, correct? Correct. And that's similar to last year that kind of came in just prior to the hearing. Yes. And what did you indicate MVP is doing based on that data? We updated our trends reflect what's in the proposed hospital budgets and is having an overall impact on the proposed increase of an additional increase of 0.5% to go to 11% in total. Now, coincidentally, what did MVP do last year to adjust based on the hospital budget proposals? And coincidentally, it was the same figure of 0.5%. And you recall what L&E did last year? L&E reviewed historical differences between rules ultimately approved and what was proposed. And their overall recommendation was to look at the historical averages and it was something greater than zero but less than 0.5%. So our opinion is that we should be working with the information that's known at this time, which is why we're building in the proposed hospital budgets for this year. And last year, where did L&E land in terms of what the percentage should be in there? If I recall, it was 0.2%. And as you sit here today, not knowing exactly what L&E's gonna do with this hospital budget issue, but as far as you know, that's the only potential dispute we have with L&E this year? Yes. There is risk in making that adjustment because historical adjustments may not be consistent with what happens for this year's hospital budgets. Last year, as we mentioned earlier, we did experience an increase this spring, which wasn't completely initially approved hospital budgets. So there is some risk in following historical averages. That said, we are again building in 0.5%, which is part of the data that's known at the time as of right now. Thank you. Matt, would you go back to the summary page, page 15, please? The third bullet references medical utilization trend. Do you see that? Yes. What is medical utilization trend? Medical utilization trend is just the change in the number of services being rendered. So there's two components to get to a total dollar trend. One is on inflation, which we discussed earlier, and the other one is on frequency, which is utilization. L&E is recommending that the medical utilization trend be increased from MVP's proposal of 0.0% to 1.0% per year, which will increase rates by approximately one point. And do you agree with that recommendation? Yes, L&E, MVP has experienced a lot of growth in this market in the last few years. L&E has the ability to analyze data from both sets of carriers, so they have a full snapshot of the QHP market. So their data and their analysis is more robust and more comprehensive than what MVP has at Spankertips for utilization trend purposes. Great. So let's go to page six of the exhibit, please, on that point. Very bottom of that page, there's a sentence that starts because, do you see that? Yes. Would you read that sentence, please? Because of the A-tip flow results produced by MVP's analysis using their own data, L&E analyzed utilization trends by using market-wide utilization data, i.e. a combination of utilization data from both QHP carriers. And that's what you were talking about a moment ago, correct? Yes, correct. If you go to page seven at the bottom, you'll see a bullet, and then you'll see two bullets that go into page eight. Do you see those? Yes. Do you see those? First bullet, L&E notes MVP's utilization trend has oscillated in recent years and has increased in 2018. Next bullet, the increased assumption is more reflective of market-wide data which is less impacted by significant shifts in membership between carriers from the bullet. L&E believes this assumption is based on more credible data than MVP's closed cohort analysis. And the last sentence makes reference to the rating increase to approximately 1.5%, doesn't it? Yes. And you agree with that, correct? Yes. Great, let's go back to page 15 and go to the next one. The next one on page 15, the next bullet is AHP morbidity impact. Do you see that? Yes. What is L&E recommending there? L&E is recommending we remove the HP morbidity load on claims which we discussed earlier, which we reduce the projected premiums by approximately 0.8%. And we discussed that earlier and MVP agrees with that, correct? Correct. Okay, you see the next bullet, high-cost member program, you see that? Yes. What is the program, please? There's a national high-cost re-insurance pool that exists because at a certain level, risk adjustment is used to normalize morbidity of populations put at a certain claim level. Risk adjustment just doesn't work on the outlier claims. So CMS identified this as an issue. If a carrier has a disproportionate share of high-cost claims in excess of the million dollars, they will receive 60% of those dollars back through this national re-insurance program. Carriers are assessed to fee based on their percentage of total nationwide premium. So in this case, MVP didn't have any members that were eligible for a recovery over a million dollars in the Vermont exchange market, but we are paying into the program because we have to pay our share of the nationwide premium. Okay, if you go back to the bullet for high-cost member program, what was the last cost, say? L&E recommends that the assumption for the federal high-cost member program be moved in the URT from risk adjustment to net re-insurance, which has no impact on the rates. So the last clause they say, no impact on rates. Do you agree with that? Yes. The next bullet is changes to risk adjustment. Do you see that? Yes. What does L&E say there? L&E is recommending that a change to our risk adjustment program will initially propose our rates to our final results within adjustment for 2020 risk adjustment coefficients is an increase of approximately 1.5%. Thank you. Would you please go to page 11 please? And you see at the bottom there's a number prepared up 10, which represents change to risk adjustment. Do you see that? Yes. This explains the rationale that L&E used correct? Correct. So the second sentence describes the data MVP act at the time of the final. Correct. Correct. Would you read that sentence? Yes. The most recent data available at submission was the interim report published by CMS in late March in the confirmation of the number of months each carrier had submitted for the interim report. So late March data, right? That's correct. And then if you turn to page 12, that first paragraph at the top, what did L&E first do? L&E requested that both carriers provide final CMS risk adjustment data in the form of the rate E file, risk adjustment transfer elements extract. They took, they gathered MVP's data, put the crosses data and computed what risk transfer payments and receipts would be for the 2018 plan year. So they used more data from both carriers? Correct. And then the second paragraph, what happened on June 28th? CMS released the final risk transfer results for the 2018 plan year, which is the same set of data that we're using to set our premium rates for 2020. And did that data, does L&E indicate that that data confirmed their prior calculus we just talked about in the first paragraph? Yes, the calculation changed with the material. And then there's a paragraph after that says, additional, do you see that paragraph? Yes. So what else did L&E do after receiving the CMS information? In addition to the CMS information, the final results, CMS is changing the coefficients or the weights for certain disease states or age gender factors in 2020. So for example, a 40 year old single male on a platinum plan in 2018 may have had a risk score of max in 2020, that may be 0.9 of max. When you take both sets of data from the carriers and simulate it using the 2020 coefficients instead of using the 2018 coefficients, the risk transfer results change and the adjustment of, which is worth approximately, what's going from MVP Bank 5561 per member per month into risk adjustment to 6415 per member per month. The 6415 PMPM is more representative of what we would anticipate to happen in 2020 because of the updated coefficients. And Matt, the reference to review clauses is because MVP has a disproportionate share of lower risk and lower benefit members, why is that significant in the status of diagnosis? Because the shift in the 2018 to the 2020 coefficients, the results, so in risk adjustment, healthier policy holders are paying into the program while higher risk policy holders are receiving money to end up at 0.38. The changes between 2018 and 2020 is gonna result in the lower morbidity population paying more into risk adjustment, which is why MVP is seeing a big increase due to the fact that we do enroll more low risk and low benefit members. And that portion of this analysis reflected an increased rate of 1.8%, is that right? Yes, that's correct. And then read the last sentence, please. Combined with the first recommendation, the overall recommended change, the risk adjustment transfer projection results in a 1.5% increase to the 2020 premium rates. And you agree with that 1.5% increase? Yes. And simply put, did L&E have significant more data to come up with that increase? That's correct. Matt, let's go back to page 15, we'll make a progress. Changes to actuarial value, you see that last bullet? Are we in exhibit 15? No, page 15. Page 15, is it not? Okay. Sorry. Let me go back. You see the last bullet, changes to actuarial value? Yes. Okay, so would you just identify what that changes, the amount of what it is? The changes to actuarial value will reflect a 0.2% decrease from to the overall look of business proposed rate increase. This is the non-standard goal to benefit design change that we had discussed earlier. MVP initially proposed a benefit design that would have no deductible in 2020. The current plan design for that plan is an $850 deductible. The result after DFR reviewed, they said that that was too large of a change to make. And we have to offer a benefit design that's closer to the 2019 plan offering, which is gonna be a reduction of benefits and therefore a corresponding reduction in premium rate. And all that is reflected in that exhibit and let it look dashed a moment ago, correct? Yes, that's correct. Was MVP, the products department in MVP contacted by DFR on Friday, about this last week? My understanding is that they were. And what did DFR call? After the initial notification from DFR to MVP, MVP modified the plan design to be close to the 2019 plan design, but still a slight reduction in deductible and a couple other different changes of benefit. DFR contacted MVP on Friday and let us know that they would like us to offer a benefit design that's even closer to the 2019 benefit design. So we're still evaluating the impact of those changes and what that exact plan design is gonna be. But as you sit here today, do you believe that change that they requested on Friday will impact this point two reduction? I do not, I do expect it to impact the gold non-standard tube premium rate, but I don't expect it to impact the overall book of business average rate increase because there's not significant amount of enrollment in that plan design. And we expect to buy something later today on that. That's my understanding, correct? So at the bottom of page 15, thank you for going through all those with me. At the bottom of page 15, that summary sentence indicates 9.4 to 10.5 pursuant to Eleanor's opinions, correct? That's correct. In your opinion, are all of these seven recommendations and the overall increase from 9.4 to 10.5 adding the 0.5 for the recent hospital budget proposals to 11%, does all that actually sound reasonable? Yes, it does all actually sound reasonable. And in your opinion, is 11% the best number? Yes. Thank you. Matt, I wonder if you could tell the board a little bit about MPP's market share and competitive posture. Over the last few years, MPP has been able to improve our competitive position and as a result we've grown from somewhere around 10% of the market a few years ago to approximately 40% of the market as of today. And we've achieved that again through trying to manage cost down and offering more affordable premium rate in the QHP market. Thank you. Next, Matt, I wanna ask you about reserves and solvents. Do you, in your opinion, contributions to reserves in isolation for just one year as it relates to solvents? We generally view solvency over the long haul. It's a little bit bold, so we want every filing to be self-supporting and be able to ensure that we're not running at an operating loss, which is gonna take down our reserve level. But over the long, we also view it as if there's one year fluctuation, as long as it's not too significant, we can manage within that. We generally don't wanna shock the market just to achieve some target reserve level. We generally would rather step into it over a few years. Thank you. Matt, would you go back and visit it to page 32? Out of the page we touched on this earlier, I wanna talk in more detail. You see the reference to contributions to reserves at 1.5%? Yes. And you justify the last year to be peace off 2%. That's correct. Okay, so let's go to exhibit 10, DFR solvency analysis. Exit at 10. Do you have this letter dated to like 10, 2019? Yes. And would you please read the sentence under some kind of opinion? The proposed rate filed by MVP HP would not negatively impact its solvency in the company, otherwise meets Vermont's financial licensing requirements. For insurer. I'm sorry, I'm sorry, I didn't hear. For a foreign insurer. Thank you. You're welcome. Do you agree with that statement? Yes. Would you go to the second page, please, and read the third bullet on the second page? Finally, in 2018, all of MVP holding companies operations in Vermont accounted for approximately 4.8% of its total premiums rate. DFR has determined that MVP HP's Vermont operations pose little risk to its solvency. Nonetheless, adequacy of rates and contribution to surplus are necessary for all health insurers to maintain strength of capital that keeps pace with claims trends. And do you agree with those statements next to bullet three? Yes. And then, would we, under the heading just below, there is this impact of the Thailand on solvency? Please read those sentences. Based on the entity-wide assessment about contingent upon GMCB actuaries finding that the proposed rate is not an adequate, DFR's opinion is that the proposed rate will not have a negative impact on MVP HP's solvency. You agree with that? Yes. In your opinion, will the increase from our original filing of 9.4% to 11% adversely impact the solvency of MVP health care team? It will not. Although our proposed rate has changed, as our CTR remained the same, 1.5%? Yes. Please go to Exit at 9, Page 14. You see a heading that says 15 changes in contribution to reserves? Yes. And this is L&E's amended report, correct? Correct. So go to the second paragraph under that heading. Okay. And you'll see there's a reference to a reasonableness check. And there's a reference to 2019. You see that? Yes. And in the next paragraph, you see the reference to 2018? Yes. Would you tell me what this reasonableness check that L&E talks about here, what that's about? L&E accessed 1600, approximately 1600, filings that were submitted in the last two years. And what they identified was that MVP's proposed CTR of 1.5% is approximately the 20th percentile, meaning out of the 1600 filings that L&E reviewed, 80% of the filings had a CTR included that was greater than 1.5%. And then the fourth paragraph under 15 starts based on L&E's evaluation. You see that paragraph? Yes. Would you please read those two sentences? Based on L&E's evaluation of MVP's CTR compared to the assumed CTR levels underlying every QHP filing submitted 2018 and 2019, L&E believes that MVP's proposed CTR is reasonable in light of its underlying risks. L&E believes that this allows the company to offset potential adverse events with appropriate consideration given to maintaining the CTR at an adequate long-term level. So I know you haven't seen, well, let me ask you, do you see the underlying data of their reasonableness checks for those two years? I have not. But based on this summary, do you agree with the two sentences you just read in paragraph four under 15? Yes. If you go down to the sixth paragraph, just above the number 16, would you read the first sentence in that paragraph first? L&E believes the CTR assumption is reasonable and does not recommend any changes to the CTR. In addition to L&E's review, L&E recommends that any solvency analysis performed by the Department of Financial Regulation be considered. And you agree with both of those statements? Yes. And then in the fifth paragraph just above, paragraph you just read, there's a reference to bad debt. Do you see that? Yes. Now, we've talked about that before, right? If you explain bad debt? Yes. There's a reference here to 0.4%. What is L&E saying about 0.4%? L&E reviewed WP's historical bad debt percentages. And over the last three years, the average amount was 0.4%, which is the amount that we're building into our proposed pre-conference for 2020. So Matt, I wanna pivot now and talk a little bit about lowering costs, promoting quality, care and access and affordability. Staying with Exhibit 9, please go to page 13. And you'll see paragraph number 13 on that page called, gee, this is an administrative cost. Do you see that? Yes. And there's two paragraphs. Can you read the last sentence in the last paragraph, please? In light of the steps taken by MAP to reduce administrative costs over the recent years, the assumed administrative 2020 costs are reasonable and appropriate. And you agree with the commentary and the two paragraphs under 13? Yes. Let's go to the first paragraph. Read the last two sentences, please. The overall rate impact is a decrease of 1%, because the premium is also increasing from the 2019 exchange filing. The administrative expenses, as a percentage of premium are decreasing. So what that means is that even though the PMPM is increasing, it's increasing at a slower rate than the proposed rate increase, which is having a dampening effect on the overall rate impact. In the second paragraph in this section, Ellen E talks a bit about the block of members in New York and their relationship with the block of members in Vermont. Correct? Correct. Can you explain that to the board and how that impacts on these percentages and increases and increases? Yes, so even though we have experienced a lot of cruelty in Vermont, that's been more than offset by contraction in our membership in our New York business. And we have a fixed cost that are spread across both states. The example I generally go to is a claims operating system. We have one claims operating system that is physically housed in New York, but it's used by members regardless of which state it's in. So the cost of maintaining that claims operating system and any kind of administrative expenses associated with it or employees, it has to be spread across MPP's entire membership base. And because the overall membership base has decreased by about 5% over the last two years, that is increasing the overall for member-per-month level. So that Eleni talks about that had been in the second pair, correct? That's correct. So given all of that, did Eleni find our changes letting the administrative costs reasonable and appropriate? Yes. Matt, first I'm gonna start with a general question for you. As in will MPP take steps to lower costs, to more quality of care and access and establish that its rates are opposed or affordable to the market? Yes. Would you please go to exhibit pocket? This is another MPP response to in this case non-actuarial pocket place, correct? That's correct. That's what it said at the beginning of exhibit pocket, correct? Correct. Would you go to page two, please? And on page two, please describe the evidence we intend to rely on to establish the rates proposed when filing for affordables and commodities. Do you see that? Yes. And then if you start on page two, you see there's a number of paragraphs that start at number one, right? Yes. And they go to 44 items. And on page six? Yes. So I wanna go through these and explain to the board how this all relates to the question of steps MPP has taken to lower costs, remote and quality of care and access and steps the rates are opposed or affordable to the market, okay? I don't think we have time to go through them in order, one through 44, identify three categories I wanna talk about. All right, let's start first with managing care and medication. Second with managing administrative costs and contracts. And then third we're gonna talk about managing the plan and membership. So let's start with the first one. And you're free to reference some of these number of paragraphs as you talk and I'll help you through them. So starting with managing care and medication, let's first talk about primary care, please. Again, keeping in mind those statutory issues that I described for you, you can talk to the board about primary care. MPP is a strong believer that primary care should be centered to a patient's medical experience. Having a regular contact, having regular contact with your PCP not only does it help establish a relationship where there can be efficiencies created because they know your medical history but they will also be able to delegate or refer care in the most efficient way possible. So if you have a solid relationship with your PCP, there are downstream effects that can help avoid future higher costs because they'll be able to even know your history and will be able to direct you appropriately. We also have a quality program in place for PCP so if they meet certain quality criteria there's financial incentives attached. So we also, in addition to trying to reduce costs down the road, it's important to us that not only is it an affordable product but it's also a high quality product. So certain metrics such as well screenings and procedures within your well screening visit are followed. Thank you. And looking at nine to three part of which is redacted just at a high level, there's a reference to a marketplace for primary care improvement program that's that. That's the program I was referencing where PCPs meets certain quality metrics through the financial incentive attached. Okay. And item six, references aligning fees to increase access. Describe that please. Yeah, so we've taken steps in recent years to ensure that there isn't as large a spread between hospital and physician reimbursement versus community physician reimbursement. It's important that the physician that's down the road in Montpelier is compensated comparably to the physicians that are employed by hospitals. And what that does is there isn't a strong incentive for physicians to only be employed by larger hospitals and it'll provide hopefully higher care in the community based physician offices. Thank you. The next item is MVPs hiring and using clinicians staff. Do you explain that to the board? Yeah, MVP employs a comprehensive staff of clinicians ranging from respiratory therapists and registered nurses all the way through MDs. And we have a number of programs in place to help members when they have a critical point in their life where they need to use medical care. So we have a transplant network in place where you have one-on-one contact with an MVP clinician to help direct you to the appropriate facility. And we only use the highest quality transplant networks because these are really high cost complex procedures that are performed. And what we wanna ensure is that there aren't downstream impacts. If you go to a lower quality transplant facility, you may not have the same outcomes. We also have a critical program where critical program in place where if a member unfortunately receives a negative or unfavorable diagnosis such as intense cancer, then we have a program in place to help contact those members and help guide them through the process because we recognize that the healthcare system is complex and especially when you're dealing with one of these life events that can be life-altering we wanna try to provide the most positive experience possible to our members. And on the front of trying to reduce costs, we also have a program in place where we analyze members that have been accessing the ER in a non-traditional fashion. So members that may have three plus ER visits in 90 days, we reach out to them and try to provide some education materials to let them know that we have other programs in place more such as our telemedicine benefit which has been great in recent years. We've seen uptake utilization and that's a great program that we'll talk about. And additionally, or we can direct them to an urgent care facility, which is a lot lower cost, somewhere between 20% less on average for the telemedicine to somewhere between, I'm sorry, I misspoke on those percentages. So we're at $45 for a telemedicine visit and can be upwards of $1,000 for a new visit. So we're really trying to promote access and provide honest cost relief. Mr. Herring officer, I don't want to interfere with their putting on their case, but in this case, Mr. Lombardo's not testifying as an actuar, right? He's testifying as an executive with knowledge of the company's policies. Is that a point of clarification or an objection? I'm sorry? Is that a point of clarification or an objection? I just want to, yeah, I would just like to make it clear that it appears that Mr. Lombardo is not testifying in his capacity as an actuar, he is testifying as a corporate executive, which is certainly a reasonable thing for him to do, but this is not actuarial testing. The only thing I would say on that is although Mr. Lombardo is wearing a suit, I don't know if he would take offense to be calling a corporate executive or not. He's a back witness, he's wearing many hats here today, he's also an expert witness, so you can draw whatever conclusions you like on his testing or he's been disclosed as such. So Matt, let's go back. You referenced by way of example some particular care management programs, some specific ones, but there's a number of those that MVP administers. I'm looking at number 10. Yes. Yeah, so we also have care management programs in place for members that are being discharged from a hospital, from an inpatient setting, trying to guide them through helping them maintain their health after they leave the hospital, which will help reduce readmissions and therefore reduce costs down the road. And Matt, you talked about a number of different types of clinicians on staff. Are there nurses available to take calls 24-7? I'm looking at number eight. Yes, MVP has a 24-7 nurse helpline available so if something happens on the middle of night or holiday where offices are closed, we can provide member with somewhat of a triage to direct them to the appropriate place or what they should actually do. And does MVP also provide health care case managers, health folks who are navigating all of this? Yeah, as I referenced earlier, we recognize that the health care system is complex and it may not be, how your claims are gonna be paid may not be the first thing on your mind if you're facing a crisis. So we have case managers to help intervene and educate and inform members and monitor whether or not members are following up with their physicians and adhering to their prescriptions. And looking at item 14, how is MVP going with Vermont members? So it's been successful. There's been 30% of Vermont members that we've specifically contacted have accepted some form of care management and we're proud of those statistics. It's to be able to achieve three out of 10 Vermont members to be willing to accept care management and help understand the health care system and how they're stepping through their policies and through their treatment. It's really great. Next Matt, I'd like to again, manage your care of medication website online tools and telemedicine, explain some of those efforts. Yeah, I do want to clarify item 22 where we quote that there was 2.1 million sessions in 2018. That figure is from after last year's rate hearing. So that's approximately six and a half months of data. We did go back and we analyzed August 1st, 2018 through the end of June of 2019, so 11 months and there was overall about 3.5 million sessions because there is a lot of really helpful information on that unique website, whether or not it's, how to go through it, whether or not it's identified where doctors are within your service area or where you're located. So the example I was providing earlier were, if you're on vacation in Arizona or California, you can still go on that unique website and find a doctor for any condition that's within a certain radius of the city or zip code where you're located. Additionally, there's a lot of great information on the website about health and wellness. And there's also information that leads you to telemedicine. So the telemedicine benefit, as I was mentioning, that provides you, if you have a cell signal, provides you with the ability to have 24-7, 365 days a year of urgent care, mental health visit with your doctor. And I utilize that benefit and I've had it with a positive experience and that's consistent with MVP's members where the vast majority of them gave it a four or five-star rating and had five stars. And, Matt, would you expand a little bit, if you go to ID25, about the online tool to locate a care provider and explain that a little bit more as it relates to Vermont? So in addition to just identifying where providers are located, there's also a cost estimate calculator that's provided so you can see what the costs are. If you're in a product that's nearby deductible and you know that you're going to pay out of pocket expense, the cost treatment calculator will estimate the cost of the procedure for various providers within your given chosen radius where you're located. Additionally, there's also a pharmacy comparison tool so you can see, again, if you're under a deductible or you have a co-insurance benefit, then it's helpful to understand what your out-of-pocket is expected to be. So you can use a similar tool for prescription drugs that will inform you what the cost of a given drug is at various pharmacies within your given drug. Thank you. There's a 24, there's a reference to welcome packets. So in contrast to the website, I thought of the outset as a way to welcome them. Whenever someone enrolls with MVP, they receive a welcome packet that tries to provide a simple understanding of the benefits that they've purchased and also provides an understanding of some common terms that are used like co-pay deductible common terms. There's been some studies that have performed that show that the average consumer doesn't even understand what those terminologies mean. I think we take it for granted sometimes because we talk this language all the time. And it's important that we can provide some sort of knowledge to our members before they start accessing care so they can have a reference point and understand exactly what they've purchased from us. And referencing item 30, is MVP providing any for folks who might enroll mid-year? Yes, we have, the website is designed to help someone that does not enroll during the open enrollment period which ends on December 15th. You may have a life event. You may get married or have a child or a change employer. And in that case, you need to enroll or you should enroll in your policy off cycle. And MVP provides tools available to members so they can understand those special enrollment periods. Thank you. Matt, the last item under this category is item 44. Can you read that please? How many of you continues to negotiate with one parent? Matt, would you go to please exhibit five A's? This is a confidential exhibit. I don't want you to say anything. Okay. And then you turn to page eight of the exhibit. What I'd like you to do is read the questions. Read four and pause. Read four A's and pause. Read four B's and pause. Allow the board to come to read the responses Okay. Number four, please describe your plans for contracting with one care Vermont in the 2020 plan year, if any. If you plan to contract with one care in the 2020 plan year, do you expect to incorporate capitated payments? Four B, if you plan to contract with one care in the 2020 plan year, do you expect this partnership to impact rates? If so, when? So generally now, what has MVP done in terms of its team at the company dealing with value-based risk sharing? MVP recognizes that the fee-for-service model has not worked and in addition to one care in Vermont, New York City has rolled out a roadmap for our Medicaid population where you have to have a certain number of contracts or a percentage of your overall dollars covered by Medicaid in some sort of risk-share arrangement. So level one risk-share arrangements are arrangements where only the carrier is taking risk. Level two arrangements are where they're shared risk between the carrier and the provider group. And level three is a capitated arrangement where only the provider is taking risk. So MVP, again, we recognize that the fee-for-service model has not been working. So we are putting additional staff towards this focus to try to improve on the contracts that we're writing and understand what's driving costs. As of right now, our experience in New York, as you know, we did not participate with one care in 2019. In New York, we've had some experience over a couple of years. The results of value-based contracting have been mixed. The one positive I'd say is, well, not the one positive, but one of the big positives is that we're sharing information with the provider groups to help inform them so they have a better understanding of what are the cost drivers? What are the items that they can try to manage and understand better? And depending on the level of arrangement that you have with MVP, there's additional information that's provided. So certain provider groups are provided with information about providers that maybe miss having higher utilization than anticipated relative to their peers or providers that are sharing information that is or that are admitting referring outside of a smaller network that would help manage costs down. Thank you. Matt, I want to go back to the five on the list of 44 and talk about the second category, which is managing administrative costs and contracts. Would you tell the board about what MVP is doing with contracts? For third party vendors that we negotiate or have vendor agreements with, we have the policies and procedures in place that to ensure that we're getting the best price possible. So you can't just hire any third party vendor. You have to have an RFP request for proposal from at least two different vendors so we can understand what is the product that they're selling and also what are the costs associated with this product. And then that helps inform our decision making to understand the balance of quality product versus cost. It also helps because when you have two or more parties against one another, you can try to leverage them to drag costs down. In the more contracting with facilities and providers and PBMs, we're going back and forth and having numerous conversations with them. In New York, there isn't a process in place like the Green Mountain Care Board oversight. So it's on the onus of the carriers to go out to providers and facilities and negotiate the best possible contracts possible. Our goal is to deliver an affordable premium rate. So in this final 89% of every premium dollar is going towards the medical or pharmacy expenses. So we recognize how important it is that we try to manage costs down. So we do go through comprehensive back and forth process with our providers and facilities to try to keep costs down to deliver the lowest premium rate possible. And on the PBM side, that's a vendor that they are actually a third party vendor. Every couple of years, we bring in numerous PBMs and try to understand what are the, what is the best, which PBM can provide us with the best discounts of ever 12 sell prices and the most reliefs. So we're, again, in the effort of trying to keep costs down to make premium rates as affordable as possible, we're going through a negotiation process with our PBMs every couple of years. And then in between those RFPs, we're actually going back to the PBM we're contracted with and doing a renegotiation to the extent it's needed. The PBM is also providing a lot of value to us in the sense that they're helping us understand as drugs are coming off the formula or as drugs are coming off the patent and we're adjusting our formularies. So just to give a little bit of background, when a drug is approved by the FDA, there's an exclusivity period. During that time period, it's deemed as a brand drug and they're generally more expensive than generic. So after the patent expires, when a generic drug is released, MVP evaluates its formulary and makes a decision if we need to make an adjustment to the formulary to remove the higher cost brand drug from the actual formulary list. Thank you. And on administrative costs, you testified that to some degree already, but how does MVP undertake initiatives to address administrative costs? Over the last handful of years, it's been a MVP corporate-wide initiative to manage our admin costs down. A number of years ago, we had identified that our administrative costs were out of line with our peers, so in an effort to improve on that charge, we've managed the costs down significantly over time. Now, as inflation has taken place and years have gone by, we do have to put some efforts towards updating technology. Health insurance is a very technologically-based industry, so we do have to put some efforts and money towards improving our technology, but otherwise, it is always our focus on trying to keep our costs down to the point where we're maintaining the set-sure reserves and meeting our set-sure reserve requirements and offering an affordable premium to the extent as possible. Thank you. Can you explain MVP's use of the nationwide network? How that works? Yes, so MVP only operates in New York and Vermont, but we also recognize that people travel all the time, whether it's for work or vacation, and at those times, you may need to access a provider. Additionally, there are points where you may not wanna go to a provider in Upstate New York or Vermont and you'd rather go somewhere like the Mayo Clinic or somewhere outside of the Northeast. So MVP contracts with another carrier, that's an HMI carrier, to ensure that you can have peace of mind and access to a high-quality provider facility regardless of where you are in the country. And then the last category, Matt, is on managing the plan and membership, which provides 34, 35, 39, 42, rather than going through each one specifically. Could you please describe how MVP's managing the plan and membership to keep costs down and address issues of affordability for another non-actual risk issue? Yeah, so we participate, the Vermont Health Connectors and ACA compliant, small group individual product offering. So we are taking advantage of the benefits included with that, which includes the advanced premium tax subsidy, which comes from the federal government and in the state of Vermont, there's an additional one and a half percent for lower income individuals. So that's helping set of ceiling on how much a given member can pay out of pocket for premium if they're meets certain federal poverty restrictions. We're also offering non-standard plans to members so that we can offer the different benefit design that we think is gonna attract them. So not everybody wants to purchase the standard benefit design. It may not be a cost sharing structure that is in their best interest. So we offer non-standard plans to try to fill those gaps for consumers. And also we're continuing to participate in the CSR program. We aren't being funded for it. By the federal government, we are receiving the Vermont funding. But on top of that, we also have the silver reflective plans as a result of the CSRD funding so that consumers that aren't eligible for APTCs or CSR can purchase a silver plan that isn't loaded up for the CSRD funding. And what about the blood classes being considered preventive? Yeah, additionally, we are undertaking initiative this year. There's been a lot of studies that have been formed that have shown that mental health, there's a lot of overlap with mental health and substance abuse disorders with overall health of a member or a person, I'd say. And we're undertaking efforts to try to insource a lot more mental health and substance abuse work and ensure that we can manage the cost of those members more effectively. Matt, if you'd go, just to wrap up this section, if you go to page two, the exhibit of exhibit five, based on all the testimonies you provided on various other factors and testimonies earlier today, can you explain how all of that could be summed up responding to issue one and two? It's important that MVP not only puts forth the most affordable premium rate relative to the benefits being offered, but also high-quality products. So we have a lot of different programs in place that we just discussed to try to ensure that not only is a member receiving an affordable product, but also a high-quality product that gives them access to providers, facilities, and pharmacies around the country. Matt, in your opinion, is there a long-term risk in making health insurance affordable for just one year and undercutting price for one year? It depends on the magnitude. In one year in isolation, if it isn't, magnitude isn't huge, then it wouldn't impact the well-operating insurance policy. But if it continues to happen year over year over year, MVP is current reserve position. MVP is down south in New York. We don't operate under RBC and over monitor RBCC, but New York's guidelines are more percent of premium base. The minimum percent of premium of reserves available for an insurer is 12.5%. Our comfort level is closer to 16 to 20%. And right now, we're somewhere in the 14.5% to 15% of premium range. As I was mentioning just a moment ago, one given year, if the magnitude of the cut isn't too severe, it won't take us from 14.5% below our 12.5% threshold. But over time, there is risk that if you can take a brief, that's continued, that our reserve position is gonna get worse and worse, closer to that 12.5% then. Thank you. Matt, I just want to go through the statutory criteria. I understand it. We have an amended rate of 10.5 increase suggested by Ellen E. with the statutory criteria. We are suggesting an additional 0.5% increase for the hospital budget proposals. That gets you 11% correct? Correct. Based on the rate filing, other evidence in your testimony today, did the MVP rates meet the standard of affordability? Yes. Based on the rate filing, other evidence submitted today, your testimony, did the rates promote quality of care and access to health care? Yes. Based on the rate filing, your testimony, other evidence submitted today, are the rates unjust, unfair, inequitable, misleading, or contrary to law? There. Is that because the rates are reasonable based on the data that we have? Yes. And are the rates actually sound and fairly charged premium for services covered in your opinion? With the adjustments? Yes. Are the rates excessive, inadequate, or unfair to the instrumentary? No. Are the rates reasonable relative to the benefits that are offered? Yes. Would you agree that rates may be considered adequate if they provide for payment of planes, administrative expenses, taxes, and regulatory fees and reasonable contingency for product purchases? Yes. So the rates here are adequate? Yes. 11%? Yes. Would you agree that rates may be considered excessive if they exceed the rate needed to provide for payments of planes, administrative expenses, taxes, regulatory fees and reasonable contingency in product purchases? Yes. So is the 11% excessive in your opinion? No, it's not. Would you agree that rates may be considered unfairly discriminatory if the rates result in premium differences, among stewards, or in similar risk categories, that one, are not permissible under applicable law, or two, in the absence of applicable law, do not reason to correspond to differences in expected costs? You agree with that standard? Yes. So is the 11% proposed by MVP unfairly discriminatory? It is not. Would you agree with me that the statutory criteria we just went through are all interrelated? Yes. They're not separately siloed? There is interdependence of them, I agree. Any adjustment to a rating increase for whatever reason, plus or minus, it all feeds into that final number, correct? That's correct. And it's important that that final number is actually sound and reasonable, correct? In this case, the 11%? Correct. In contrast, excuse me, and if the board cuts the final number based on a non-actuarial ground, would that adequacy of the rate be in jeopardy? Yes. And in contrast, based on your testimony of the other evidence, it's in evidence that the insurance product is affordable with the 11% increase, in your opinion, does that strike the right balance under all the statutory criteria? It does. Is that the best rate in your view for 2020? Yes. Thank you very much. Finished with questions? I am. Mr. Annoff, do you have questions for this? Yes, I do. Martin, Mr. Lombardo. Martin, Mr. Annoff, how are you? I'd just like to make sure that I understand and make sure that the board understands certain concepts. Would you mind turning to page 2, page 23, page 3 of the amended rating? Page 23? Yes, page 3 of the amended rate filing. I'll pick that up in a minute. You're there? The title of the title is Experience Period Plan. Correct. Correct. Okay. And in the last paragraph there, you talked about IV and R, if you see that. Yes. Could you explain to the board what IV and R is? IV and R is an estimate of your house and A-line building. So if you go to the doctor today, the claim may not be paid for three months or so. And based on statutory guidance, and so you can evaluate and ensure reserve or claim adequacy, and there are income statements. You have to hold appropriate reserve levels. Those reserve levels are audited by a certain party every year to ensure that they're within a range of reasons. So is it fair to say then, when you include IV and R, that is your best estimate of how much you're ultimately going to pay out? Yes. Okay. You're not including any fudge factor or any variance, that's your best estimate. That's what that says. Very good. Can you turn to page 7, or page 27 of these other two? Okay. And there you discuss what you originally were going to do with respect to A-H pays. I'm sorry. There you discuss what you were originally going to do based on what was A-H-P, what was the law relating to A-H-P's when you filed your rate filing. I just want to make sure that I understand what the ultimate outcome is. Originally, is it fair to say you were going to raise rates by 1% because A-H-P's were going to be allowed in Vermont in 2020? That's a true statement. Okay. And based on the the DFR guidance and the federal court case striking down the federal rule in A-H-P's, it's now the case, isn't it, that in Vermont A-H-P's will not be allowed to be sold in 2020. That is my understanding. And therefore, you no longer include that 1% that you originally included based on what was then the law with respect to A-H-P's. That's correct. Okay. And let me just make sure I understand the arithmetic. You were going to raise rates by 1% and I thought I saw a number in here or maybe it was in the L&E's report saying that because A-H-P's are not going to be allowed in 2020, the rate comes down by 0.8% not 1%. Could you explain the arithmetic there? This is a claim adjustment, the 0.8% is also considering the impact of our administrative loads and taxes and fees and CTR. Okay. So the administrative load and CTR aside, if you're going to put those aside for a second, if you're going to make a change that raises rates by 1% and you decide not to make that change, does that mean that that 1% proposed increase is no longer applicable? It's a 1% claim adjustment. So you do have to account for the target loss ratio of approximately 89% which is where you arrive at the 0.8% plus it's the reciprocal. So it's one divided by that number. So the 0.8% is the result of those two different items. So is the result of what two different items? Adjusting for administrative expenses and taxes and fees and CTR as well as the fact that it's just an arithmetic thing, you have to flip the numbers around. So 110 divided by 100 is plus 10% but 100 divided by 110 is exactly minus 10%. I get it. Did you say earlier that MVP in the past year did not get into the AHP business at all? That's correct. And why was that? At the time, the ruling was passed after we had the ability to adjust and even contacting AHPs and for submit a filing for 2019. Beyond that, I really was not involved in those conversations. So I can't really provide any more input. Okay. And did you make any assumption as to what would happen to the people currently in AHPs in 2020? In putting together your rate filing? Could you clarify exactly? Yeah, so there'll be no new people in AHPs in 2020, correct? Well, my understanding is that there will not be new people in AHPs in 2020. There also will not be the existing people that are enrolled in AHPs in 2019. They'll have to either, they'll have to find insurance coverage through the Vermont Health Connect or another way. Okay. And what did you assume about those people in AHPs in 2019 who would have to find new coverage? We assume that the members that left the Vermont Health Connect market and went to AHPs who were materially healthier than the members at state and AHPs. We assumed that we would see a similar transition in 2020. So there was a second year adjustment as well. So you assumed that at least some of those people would come back to MVP, correct? What's on page 27 of this document is assuming that there's gonna be more members leaving the Vermont Health Connect market because the rates that are offered by AHPs by our competitor are more aligned with MVP's exchange rates. So we were anticipating a similar migration in 2020 away from MVP, nobody coming back to MVP. You're assuming that no one currently in AHP would come back to MVP. In the submitted rates in the amended filing that we're reviewing? I'm sorry, no. Now, based on the law today, what, if anything, are you assuming as to the extent to which people now in the AHPs would come back to MVP? Well, we're hoping to attract more than the approximately 1,000 members that we expect that we lost. All that said, the way that premium rates are set, it's based on market-wide average risk. So if they come back into the market, once we take our claims from 2018 and adjust for risk adjustment, our rates would not change based on if they came to us or if they went back to Blue Cross. Okay, so those people are healthier than the average in the market, right? They're healthier than the members that MVP was insured. But you're not assuming that, you're not assuming any right decrease for people, for those people who are healthier who would come back to MVP. Again, it's because we're pricing to market-wide average risk. So their lower claim costs will be offset by a payment into risk adjustment, which is captured in our 2018 data because HBs do not exist. Once you account for the fact that we're paying to risk adjustment, then that gets us to the market-wide average risk prior to HBs existing. So you're not assuming any separate rate reduction because of the people who would come back to MVP who are now in the AHP market? I'm not. I'm sorry? We are not. The deterrent page that leads to page six, oh, sorry, page 26, the little number six. Okay. And in the middle of the page, you see the paragraph beginning line between adjustment for individual mandate penalty set to zero? Yes. Okay. Am I correct in understanding the following? That last year MVP assumed that because the individual mandate penalty was zero, that was an approximate 2% increase because MVP assumed that the healthiest people would be because of the zero penalty in the individual mandate, correct? I don't recall the exact adjustment, but we did have an upward adjustment for what you described. Okay. And MVP wasn't alone in assuming that, right? That's correct. In fact, you were right on a study by L&E which said essentially the same thing, right? Yeah, we did our own study and they were comparable and we adopted L&E's analysis. Okay, but in fact, you found that there was no effect of the zero penalty for the individual mandate, correct? In the Vermont Health Connect market, we did not see any change in 2019 in the individual marketplace enrollment. So you took out the, so explain what you did then in this filing with respect to the individual mandate. We're not making an adjustment because we're seeing that the 2019 enrollment is comparable to 2018 enrollment so that adjustment isn't warranted. And so how much does that reduce the rate by? I would have to go back to the 2019 filing. I don't know that one on the top of my head. Okay, but it's the same amount as it was in the 2019 filing. Yes. You're not assuming that, strike that, that's fine. Could you turn to page four please? 24 or four? Page 24 of exhibit two, page four of the rate file. And do you see on the bottom of that page there was discussion about a pooling charge? Yes. Could you explain to the board what the pooling charge is? Yeah, claims, high cost claims are very volatile. So in general, your claim curve will kind of look similar for year to year. Not to get too much into the actual area of the cangis but if you were to really zoom in on just that last 5% or so claimants, the really high cost claimants, there's a lot of annual volatility for year to year. So we chose $100,000 and $100,000 and we analyze three years of data to understand the historical average of that claim volatility and the average claims are in excess of $100,000. We remove claims over $100,000 from the experience period and then we replace that with the historical three-year average. So is that methodology that you found in past years too that you've always used the historical three-year average? Yes. Did you consider, and when you say high cost claims, in this case, what you mean by high cost claims is claims exceeding $100,000, right? That's correct. Okay, and you see the table on the top of page 25? Yes. Okay, and you see there the percentage of high cost claims has decreased over the last three years, right? Yes, that is the trend that we've seen in recent years. Did you consider the possibility that maybe the trend is downward and therefore instead of taking a three-year average, you should wait the most recent year, either wait the most recent year the most heavily, or you're going to assume that the downward trend is going to continue? Did you consider that? We had conversations about that, but it truly is incredibly volatile from one year to the next. Additionally, these high cost claims, as we've grown our enrollment, Ellen even commented in their opinion that we are ensuring lower cost, lower benefit members. So you would see a potentially a decrease in here, which you're paying back in, but again, there's so many back into your risk adjustment, but you are, there is so much volatility if you look at the tail of any carrier's claims from year to year. For example, there is the national re-insurance pool of $1 million that we were talking about. Re-insurance pool, the national re-insurance pool that we discussed earlier, and while MVP didn't have any claims exceeding that threshold in Vermont, we did experience some in our New York markets, but then in prior years before that, we didn't experience any of those claimants in our New York markets. You're talking now though about claims exceeding $1 million, right? Yes. Okay, so when you said there's a lot of volatility, you were referring initially weren't to the claims above $100,000? Yes. Okay, and the chart on the page of top, the top of page five shows high cost claims decreasing from 16.8% to 10.5% over three years. Do you view that decrease as the difference between the 16.8 and 10.5 as highly volatile? There is significant volatility in claims over $100,000. And so is that 16.5 to the 16.8 to 10.5? Is that the basis for your conclusion that there's significant volatility? That's the basis of our 12.5% adjustment. Is it the basis for your conclusion that there's significant volatility? No, that's just based on a lot of other actuarial studies and data that we've analyzed that there is significant volatility. Do you happen to recall what the highest percentage of high cost claims was in the years that you've been reviewing these claims in Vermont? I do not. Would it be more than 20%? I do not recall what the overall range was. This is what I have in front of me and this is what I can speak to you right now. Would you be surprised if it were over 20%? I wouldn't be surprised if it were over 20%. I also wouldn't be surprised if it were less than 10.5. Can you turn please to page eight? I'm sorry, page 20. Take eight and exhibit page 28 of the exhibit. We were just discussing this. This is in the line 21. You see that adjustment for national high cost re-insurance pool. Yes. And you said that the 0.24% by which you're raising rates should not be reduced because you don't anticipate a, you haven't had and you don't anticipate any claims above one million in Vermont, correct? It's not a projection of what we anticipate is what happened in the 2018 experience period that we're using to set our rates. If there were a claimant in 2018 that were in excess of $1 million, we would be capturing the impact of the recovery from the CMS national re-insurance pool in the redevelopment and then also building in the charge that we would have to pay to the program. You do say, don't you, in the last paragraph under line 21 that you do not anticipate any claimants for the raising period? That is, yes, that is the CMS you mean. Do you know whether page two of that exhibit you are going through with Mr. Carnegie, some of the 44 things that MVP is doing, many of which are clearly laudable to reduce costs, correct? Correct. Right. Of all those 40, can you point to any of those 44 which include or refer to any data demonstrating that Vermonters can afford what MVP is selling? We're presenting is data to show to support that we're putting forth a rate that's affordable relative to the benefits being offered and we're doing our best to manage costs down while also providing access, quality, and quality care. No question that these 44 things are, as I said, laudable, you're trying to reduce costs, you're trying to improve quality, but can you point to any data demonstrating that Vermonters can afford what MVP is selling? We do not address affordability of these benefits relative to what a Vermonter can afford. We are also limited in a lot of regards by the federal government, APTC, and CSR regulation. So for certain policyholders, they are just bound to whatever the APTC amounts are but outside of that, we aren't addressing anything in terms of if a Vermonter can deem this as an affordable product. Your senior leader actuarial services, correct? That is my test. Are you senior leader actuarial services for only Vermonter for the whole company? The whole company. Okay. Then you're familiar with MVP's New York rate filing, correct? Correct. Okay. How much of an increase did MVP ask for in New York this year? I would have to refer back to it. So I'd have to refer back to it in order to be speculation. But one given rate increase in a market in Vermont versus New York, everything is relative to one another. So to the extent that there's adjustments that are applicable in Vermont or just the trends that we're offered that are being proposed are different, that's going to impact the rate increases that we're putting forth. That's the thing, find the order, get an opportunity to ask questions or if you want to start down at the end of the day of the run. Sure. Good morning. How are you? I was going to use a different one because I got this change between one and two. Page 12. Yeah, was it page 12? Yes. Some of the incense to your current wellness benefit. Did you describe this to us, please? Yes, so there's three different components to the wellness benefit. Each of them provides a subscriber of up to $200 in reimbursement. One of them would be reimbursements for healthy activities like whether it's youth sports activities or a lift ticket at a speed at a mountain. That's $200 that you can receive. Another $200 is for receiving a personal health assessment and biometric screening. And then if you don't meet the 200 point requirement that's associated with those items, you can take, there's videos or there's consultation that you can receive to help understand ways to manage your weight or diabetes or smoking cessation items like that. And then the last $200 is attached to members or subscribers that have a wearable device. If you average a certain number of steps per quarter per day on average, then you can receive $50 per quarter from being on the criteria. And so what was the enhancement? Is that a new wellness benefit? How does it change from last year? Last year we were only covering gym reimbursement and the activities and was that a lower threshold? This year it's, and I believe the adjustment was, or the reimbursement was $50, and this year it's $600 in total. I would have to double check on the 50s if that's the correct number, but that's what I would call. Okay, thank you. Keeping in mind that part of the panel, could you talk a little bit about what quality measures you're looking at in your primary care groupment program? Is that something that I don't know the exact specifics of what we're providing? We can go back, I can go back and follow up with the team that is in that program. That would be helpful, yeah. You could give us information on the quality measures, that would be helpful. Do you happen to know if those quality measures are aligned with the set of quality measures that are looked at either in the Vermont all-care model or the Vermont ACO program? I don't specifically, I don't want to speculate, so I'll just start taking notes. That sounds, I also wanted to ask you a little bit about your New York experience. So you talked about how New York has a Disrib Medicaid program that has three different levels of payment methodologies. Which payment methodology are you participating with in New York? Currently, we don't have any level three full-capitation arrangements. We do have a number of level one and level two arrangements. Generally speaking, when we, the first year of contract with a provider group, they generally are only willing to take the level one agreement and then we sign a multi-year contract and as the contract progresses, it makes step up from level one to level two. And is the primary purpose of that to allow the provider group time to adjust to the new methodology payment methodology? The level one initial, the outset here, is that what you're speaking to? Yeah, I think it's to get used to the methodology. It's also, it's also, it's challenging for them to just step into an agreement when they don't understand when they haven't necessarily been managing care in that same way. So, it's, they're on will. There's been more challenges getting a provider group to sign contracts in the initial years that where they're taking risk until they have more data than fingertips. Again, one of the pros of the database arrangements is that more data is being shared between carriers and providers. So as they accumulate more data, then they can start to be able to manage costs more effectively and that's when they generally step up from level one to level two in the contracts. Have you changed your care management programs in any way to adjust for that new value-based program? That's, you know, that's another one where I have to follow up with the team on it. I can make no exception. That would be great. And you talked a little bit about in the same exhibit the care management that you do, including a telemedicine program. And my recollection of your testimony was that actually if we turn to page five, that's four to five is what you describe the telemedicine program. So when a telemonitor is using that telemedicine program, they're not reaching their Vermont providers, that right? That's correct. And how does the information from the telemedicine visit get back to the Vermont primary care provider? My understanding is that it will be based on the level of the consent that's available. Electronic records can be shared if the member consents. Now, to the extent that the telemedicine benefit information is transmitted back to the PCP in Vermont. I'm not 100% sure of that. Okay, so it's not like the benefit comes with something like the patient ping technology, for example, that would alert the primary care provider that their patient had received a telemedicine visit from another provider. I'm not aware of that. Thank you. On page six of this same exhibit, number 38, you describe your utilization management program as designed to decrease unwarranted variations in care and support appropriate rehabilitation. Do you have any information about trends or specific areas of unwarranted variation that you would could speak to in terms of the Vermont population? I would have to refer that one back to the medical team as well. Great, thank you. On page seven of that exhibit, do you describe litigation that you're involved with? Do you have any information since the time of filing to update on this question? I'm sorry, what's that? On page seven, you describe litigation that your company has involved in and it includes the fact that there might be an entry and final judgment in June or July 2019. I'm wondering if you've received that judgment. I am not, no one has transmitted or provided any information to me. I did reach out for our legal team last week and I haven't read back from them online. Okay. If you have, could you please let us know? Yeah. The other question I had was about the new ambulatory surgical center that's opened in Vermont. At the time of filing of the materials, you could not finalize information with that company. I'm wondering if you could give us an update about that. We did contact our contracting team to understand this was a few weeks ago so it's not that today. If any contract has been finalized and the feedback they've received was it has not yet been finalized. Did you check on that and update? Yes. Perfect. Tell me, I'm sorry. So my first question just has to offer some context here for this discussion and I refer to exhibit 11 which was the paper led to show the impact on the various plans with the fix that the UNR requested for the whole plan. And I'm looking at the numbers in terms of the projected 2020 premium versus the current 2019 premium. And that's 204.3 million versus 188.6 million which is a change of about 15.6 million. Yeah, I'm sorry. Which page are we? It is 18.6, projected 2020 off through this amendment at 204.3 million. And that's a change of 15.6, 15.7 million dollars. Okay. So that's the change that we're talking about here in terms of the sense of scale. And we're kind of both you and Ellen and me kind of parse that into 16 different pieces in terms of the moving parts. And in my experience, which is certainly not in terms of healthcare projections but in terms of the state budget, we do the same thing actuarially with economists to try to figure out where we're going to be down the road. And as always tells me, we're never right. There's always a margin of error around it. And so I'm looking at this change in the context of your rapid growth in membership in Vermont. So it's not that there's a stable experience, settle scenario here. You've really picked up more for sure and you grow rapidly. So you think, and one other context here is that you're looking at an MLR in this filing at 90.6, which is an important number to me because it connects the two biggest moving parts which are premiums and claims. So do you sense that that looking at past filings going back into 2016, that number has been very volatile. And I'm wondering if you feel that it is kind of settling into a range that you have really solid confidence about? The MLR, so there's items that are outside of our control and some of the MLR items, for example, the ACA insurer tax. The federal government has had a moratorium one or two years and then they read the state of it. So that's a 1% charge that is out of our control that is gonna directly impact the loss ratio from year to year. So in the 2019 range, we did not have an ACA charge of 1% built in but this year we have to build that ACA charge back in. So that's gonna cause a swing. Additionally, we do have a fixed PMPM administrative load. So depending on how the clean projection is changing relative to our administrative changes from year to year, that's gonna have an impact on our loss ratio. So I would say that the MLR, the target MLR, there's some items that are outside of our control. So I wouldn't feel confident that what we have today is gonna be predictive of what exists in the future. I wouldn't expect significant changes for the items that MVP control unless there's a dramatic change in clean trends in future years. Well, that's helpful. And so I'm wondering if you can do this. I'm looking back at the MLRs that were the filings in 2016, 17, or 18, and they were 91.3, 91.6, and 89.7 according to your supplemental filings with the National Association of Insurance Commissioners. But the actual MLRs on those same documents are at 99.5%, 77.1%, 91.9% respectively. So there's a lot of noise there, and I don't, you know, it would be helpful if you could go back and look at those and then kind of connect the dots in terms of what the major movie parts are between what you predicted into filing or the target into filing and how things actually unfolded. Yeah, I can actually speak to one or two of those items. I know in 18, one of the items that's driving the, so first I'll caveat that the NAIC filing is separate. The way that it's measured, there's a lot of prior year noise that can be built into it. So for example, we don't receive our final risk adjustment results. We didn't receive our 2018 risk adjustment results until June 28th or somewhere around there of 2019. But we have to close our books at the end of December of 2018. We make an assumption at that point about what we anticipate our risk adjustment payment to be or receive depending on the market. So if you look in the NAIC filing, it, you know, I will just say that there is a lot of that noise from year to year that can be influencing our loss ratios. Additionally, what's reflected in the fourth quarter of 2017 and 2018 is the CSRD funding. So there's gonna be some variances from expectation because of our liabilities that we didn't collect premium for. That would be just be helpful to have that because it's not clear in the NAIC documents of what that variance and volatility are. My next question is again looking at page six on exhibit 11, that profiles the 2019 premiums by plan. And so I'm looking at, for example, those numbers relative to federal poverty levels. And so to me there is a really stark contrast between those plans below 400% of poverty and or customers below 400% of poverty and those above 400% of poverty. And it's a wall, it's not a gradual place at all. And by over the year, we've worked with Diva a bit to just kind of figure out what that wall looks like. And if I can tell you what we found, if we could talk about it or if. So if you're looking at someone just like a 399% of poverty for a bronze plan, for a single, and this is for a bronze plan, the single premium was $426, which you'll find on that exhibit, 800. But the premium, excuse me, let me step back. The established premium was $426 a month. Someone below 400% of poverty, just below 400% of poverty, was paying $203 or 5.1% of their income. On the other side, that 400%, someone that's at 401%, they were paying the full premium because there's no subsidy at all. And that's 9.36% of their income. Similarly, for a couple, if you're just below the 400% line, you're paying $150 a month, that's 2.73%, just for the premium that go-face you did at people's staff outstanding. But someone right across that line is at $832 or 13.8%. That's how it continues up through adults and family. And it's hard for me to see a couple in Vermont that's at face $65,000 to people in the 40s and 50s working concerned about health care issues and not enough to say nothing's gonna ever happen to me and to be in a position of having to pay 13.8% like 13.8% of their income just for the premium. And I'm wondering if you have any, if you look at my current vote last year on your proposal, I came out of the box with an opinion talking about my real concern about affordability. And I'm just, and I think I laid out a plan could be debated or not, a plan to address this. I personally don't think it would cost that much to close that gap between 400 and 400% of poverty for 450 to 500, because if you take the federal standard at about 9.8% of income as affordable or that wage close is pretty rapidly. So I'm wondering what thoughts you might have about how we can address that, that cliff. Yeah, that's, I guess, all very true and very real. My general thought is the safeguards that are in place under the federal ACA and also the conditional subsidies from Vermont, other than as a carrier where we are trying our best to put forth the lowest premium possible relative to the benefits of a covering as, which is met with the growth in our market share. But to address what you're referencing it almost feels like a change in legislation would be needed. That's something that I don't, public policy, I don't really want to step and point into those waters, but if outside of some sort of public policy change or legislative change, that would be the way that I would think about that initially. Well, and I know spending happy spend years at the State House, that you do have representation in the State House, and I agree with you that it is a legislative issue, but it loads back to these premiums and through the percentage of people's incomes that they're kind of, you kind of have insurance at all. My next question is just in terms of moving from the proposed, from the rearview mirror of the hospital budgets to the proposed budgets, as a standard, what level of detail have you got? We haven't even seen those budgets yet. We haven't had hearings on the 20-point budget, but yet they're cold for being used in this process. And I'm just wondering what kind of level of actuarial work that you've done on those 2020 budgets in terms of Medicaid share, Medicare share, commercial share, bad debt, free care, all those moving parts that go into that budget process have not been scrubbed yet. We're using one of the net patient revenue changes that the hospitals are proposing for all categories of... That would be flexible here, so commercial. And that's the best estimate of how our actual refiling and our clean costs would be. Have you gotten back and looked at the history of what hospitals submit and what the board has approved as a guide? Well, I know Melanie last year used that information to inform their recommendation for the adjustment between the rules and our rates versus proposed hospital budgets versus what they ultimately expected to be approved. Now, our approach is that we should use the best data available because what has happened in past years may not be indicative of what is gonna happen this year. So the best data we have available to us right now is the proposed hospital. Now, I understand it's a data point, but what's interesting in most of this review process, it is a rear-view mirror of whether it's pharmacy or mental trends or administrative trends. You know, it's looking at the reviewer and trying to statistically predict forward, walk forward in here. We're taking a data point that's out in the future. It's inconsistent, I think, the current number with the all-fare model target is 2.5%, and the board hasn't even had time to visit that. So it kind of doesn't fit the scenario most of the other data that's being used in setting these rates. My next question is having to do with the cost shift in terms of your actuarial work. I went through and looked into filings for a number for the cost shift, because it's certainly something that that the commercial carriers have to deal with, even though it's kind of a hidden, a hidden pressure. The board, by statute, Vermont has to measure annually what the cost shift is. And for 2019, the estimate is that it's in the range of $216 million. So it is a big number. And I look at the appropriations in the state budget for 2020. And for the key appropriation, that's Medicaid expenditures, which is the Medicaid local commitment line item. For 2018, the total appropriation was $719 million. For 2019, it was $731 million, or just a 1.7% increase. And for 2020, it was $738 million, which is the 9 tenths of 1% increase. And that includes the $1.1 million increase for an expansive dental benefit. So these are the numbers that we're looking at relative to a Medicaid program that serves about 22% of Vermont for moderate. And here we are with you folks looking at plus or minus 10% for a much smaller share. So I'm just wondering what your thoughts are on the cost shift and whether it's just, from your perspective, just indebted in the trend data and it is what it is, or it's something that needs to be addressed. It is implicitly included in the trend that we have included in the filing, but proposed trend. Now, whether or not that is problematic, that's a debate that's outside of the actual scope. I agree with you that the fact that Medicaid is not going on at the same rate as what other providers or facilities can be to run the business, that is definitely resulting in higher cost trends in the commercial market. But our job is to set forth a rate that is adequate for what's being covered and whose, fortunately, that cost shift is included in those trend over the years. Well, maybe we can change that over time, I bet. My next question has to do with is the employer share in the small market. It was a study in 2015 that indicated that in the small employer market that between 66% and 75% of the point was supported by the employer. And that's a 2015 number, and I'm just wondering if you have any sense of where that might be now. No, that's off the mess outside of my scope. And that's it. Thank you. Thank you. Thank you. Can you just turn to exhibit seven, here's two. I'm just looking at, again, this is a similar version of the current reference to earlier one. I was brought out of the 2017 differences between the post-actual, the loud-actual. And I'm wondering if you could, not only for our RIS trend, but also for medical costs and utilization. I'm wondering if you could, on the one hand, speak a little bit further about some of those differences and also when we might see and when it might be available in the 2018 actuals that would go with that. Yeah, 2018, we should be able to provide that. We have not run out of this point or that's something that we should be able to provide. I just want to be sure that I'm understanding this is the final 4-18 correct in the 18 column, I believe that's the case. So yeah, we would have 18 over 17 at this point because we have enough run out. I guess I'll go back to what I was addressing earlier with differences in the loud versus our proposed and actuals. It's really driven because of our membership changes, it can be driven substantially by how much our membership has been changing. So this would be fair to say that over time the differences between the police and actual and your market stabilizes would be closer? I would assume, especially as our population has gotten larger, because a smaller data set, we had 10,000 members in 2017. While that sounds like a big number, it can take a few costs or a few high postulations, can really drive that actual trend figure to be much higher than we would expect. So there's a lot more volatility as you accumulate more data, you have more stable population, then you shouldn't see as many changes as long as the benefits being covered are comparable. That said, we did an interesting review of our claim cost distribution, and it was really telling to us that 50% of the lowest 50% costs, or lowest utilization of members will be accounted for somewhere in the four to 5% range of overall costs for a commercial bucket business. And then the highest 5% cost members accounted for 50%. So they're kind of flipped around. The curve rises very steeply, right? So to the extent that in that tail, where it's so volatile from one year to the next, just changes by one to two members or one really high cost member maybe only had, I know we used $100,000 as our pulling point, but suppose that the average cost over 100,000 in one year is only $105,000, and the next year, you have the same number of people over 100,000, but it's the average cost of $125,000, that can have a really substantial impact on your overall playing trend. So yeah, those changes, there's a lot that can go into an actual trend figure that you really have to kind of peel back beyond the end. Thank you so much. So you'll follow up on the 2019 end. So actually the second question then, and we've talked about this market share that MDP has gained in the last few years, 10% of the market, QHP market in 2016 to 40% now, and clearly when you submitted the rate filing, you did not know the competitors rate filing at that point in time. So I'm wondering, what are you assuming now, given that you have a better idea than landscape for 2020, what is the expected growth in market share that you might anticipate? It really depends on what the ultimate rate increase is. As they currently stand, based on L&E's recommendations, we expect our relative position to be comparable to where we were in 2019, and I think it's gonna be a little bit different. So we're around one, excuse me, who crosses exact recommended, but I think it was somewhere in that 11 range. So largely we expect our position to be unchanged, but given the spread that we're seeing right now, we're optimistic that we can continue to grow market share. What is our kind of, I don't know what the maximum level would be, I think that's really contingent on the ultimate for great increase, and just continuing to market to our consumers and make people in Vermont, make Vermonters more aware of MDP's product. So I guess an apartment question was driven by, if more people migrate to MDP, would, for example, your estimate of the per member per month administrative cost of $42 be correct, or if more people migrate, and you're spreading those fixed costs over, or individuals, would you have to make the adjustments of that estimate? It's a matter of understanding our fixed cost broken out by Vermont versus enterprise life. That would be the level of detail that we have to understand before we would be comfortable making a definitive statement about that. I noticed that you adjusted the premiums from top slightly from the narrative that there's going to be an extra year. Does that mean next year we'll have the investment down because there'll be one last year of your experience period that you're in? Yeah, when we're using 2020 data, we'll definitely back out, we'll do 365 over 366. I believe we did that in the 2018 filing where we used 2016 data. Okay, we'll start with back to the other direction. Go ahead. So I think I was struck by some of the differences in unit cost increases for providers that were regulated by the Green Mountain Care Board and providers that are outside of the regulatory authority of the Green Mountain Care Board. In fact, the unit cost increases twice as much for those outside of what the Green Mountain Care Board regulates. And that side of the category was quite substantial. I recommend there was an adjustment to at least 40% of the spend that's happening outside of what the Green Mountain Care Board regulates. My understanding is that is growing, right? That portion of the spend that's happening outside of what the Green Mountain Care Board regulates is growing. Can you just speak a little bit to what's happening outside, why it has grown towards providers, whether that be New York, New Hampshire, Massachusetts, Florida, where that's happening, why it's growing, and what we can foresee about expenditure growth as the pattern. Yeah, so I would, in New York, we are doing our best to try to manage costs down. It's generally when we, at the outset of negotiations with the provider facility, there's usually a pretty big spread. We generally come out with a number that's probably around zero, close to zero, and then they come out with a much larger number. And we have to always balance the importance of having an adequate network with access for our members versus costs. So there's a lot of, there are a number of facilities where if you were to remove that facility from our network, then the product itself would then become unappealing. It would not be a marketable figure. So it's kind of a negotiation of how much of that, how much negotiating power do we actually have. That's the one item. In terms of members traveling or going outside of our jerseys, or outside of work we manage costs in New York, in Vermont, we do rely on a third party. We do update our contractors with them, but we are generally receiving whatever their discounts are at given facilities. So my understanding is that there isn't some sort of secondary fee schedule that we're paying that's impacting us. But we do feel that being able to provide members with access to whether it's a facility like Dartmouth-Hitchcock, who we negotiate with, or Mass General or Voss, and who we rely on third party vendor or Sloan Kettering in New York City, those are all, it's important to have that access because not only costs may be more expensive at those facilities, but it's also, those are also centered in excellence where there could be downstream impacts of that are actually reducing costs. You may pay more upfront, and then have fewer costs down the road. Why do you see more migration to those facilities outside of the remat care board for addiction? It sounded like there was more migration out there. Do you know what's driving that? I also talked to my head, I couldn't speak to that. It may just be the conditions or the location of our members. Thank you for that. Was when you're selecting your network, how much weight do you place on the price that you can negotiate versus the quality of the provider? How do you even assess quality of providers when you're thinking about your network? Yeah, we have, so we have a accreditation that providers are credentialing that providers have to go through to actually be part of the network. So there is at least a minimum floor of quality that you have to meet. We're currently undertaking an analysis of cost efficiency, which is bound to a quality. So we are trying to identify who are the bad actors, as you can say, on both fronts in terms of who those that have low-quality and higher-than-average costs. And that also balances that with high-quality and high-cost. So the line, I guess, is our credentialing now above and beyond that. We're undertaking that project right now. It's a really, so I've been just introduced to this project. It's really complicated at this point because to understand cost, you have to try to capture all the, all the trip notes. So you're trying to isolate the cost by the provider, but you have to also isolate the referral patterns, and you have to get apples apples comparisons for like procedures so you don't want to compare a provider that's doing a lot of routine services against a similar provider and seems specialty is doing more high-intensity procedures. So you have to really isolate all those different metrics. So we are undertaking that initiative. It's proving to be a very challenging initiative, but it's more to be determined. Well, I would say I would add on to that. We're very interested in hearing more about that. I think in what is the potential impact rates that you can identify providers who are low-value, high-cost providers and not potentially do paying for those services. I would imagine that would help consumers. But like Rob, I think I'm interested in your work in the follow-up on the un-warranted variation in medical care for the mock population and understanding more about what you're doing to think about that. And I'm also wondering in particular, if does MVP ever drop providers, for example, as you described, the bad actors with those providers who have high-frequency renditions or surgery, do-overs, or other kind of metrics by which you can really say this is probably poor quality care and we don't want to pay for it. Does MVP drop providers like that? I see you give carrots for high-performing performance. Do you give sticks for performance? Yeah, if those metrics then lead to those poor quality measures, then lead to either not meeting credentials, standards, or a certain, if we want to go forth. Once we have our analysis completed, if we identify who these providers are, the goal would be to remove them from the benefits lines. Or at least offer a subset of benefits. I won't tell you that we did offer a couple of years ago, we had a, for about three years, we offered a limited network product in our New York population, which had a price decrement of approximately 10%, now it's somewhere in the 9% to 10% range. And we actually stopped offering it because when we contacted consumers and asked why, they said, well, this was a robust hospital system down in a bit from the hospital in New York, North New York City. Consumers said, we wanted more access to providers, so we're trying to understand what that right balance is between quality costs and basically what is the market. It's something that we are undertaking, I can tell you that. Well, welcome to the Triple A, right? I'm following in access for all kinds of figures about that. My last question actually smells related to that. How many QHP members do you know are using that online tool? Now, my tool came on for cost, quality, or mostly cost comparison tool. In the first couple of years, there was not a lot of traffic to that website. Has the traffic grown? At least in our population here in the park. I don't have contact with our marketing team for that data. But I'm wondering, does it have any impact? Also, they might know, has it had any impact on changing traffic patterns of where people see care? They know the actual cost of the care. Yeah, that would be something that I would have to contact the marketing department for. Great, those are my questions. Thank you, Matt. You're welcome. Thank you. I'm gonna piggyback on some of the questions that were previously asked. But if we look at the high cost claim, I was also struck by how it was going down here over the year in the 628, the 2.6, the 1.5, to get to the 12.5. And I believe you stated, or in the documentation, there was an increase to premiums that that was causing 1.6 percent. That sounds reasonable. I believe the experience period claims were less than the pooling charge that some of the amount that we removed was less than what was added back in for the three-year average. That's an excellent point, isn't it? And just to go on some of the prior questioning, I mean, the trend, it doesn't seem like it's erratic. It's been going out pretty soon, 16.8, 13.6, 10.5. So to go with the 12.5, I mean, if we had gone with a lower number on the 10.5, then that sort of would have been a lower increase to premiums, correct? Yes, that number was lower, it would have been a lower increase to premiums, correct? That's right. I also looked at it. I think one of the things that has been happening year-over-year is you do keep increasing, obviously, in Vermont, and it's based on assumptions that you put in. And I appreciate that you've been declining in New York as well. And I did look back to see what you have said in the past, and you've said it was about 50, 50, 60, 40 between fixed and variable cost. And so because each year you come in and you face the year on the current year's membership, I went back and looked at, for 19, based on 25,000 and even at 30,000. And if I just used 50, 50 and said 50 variable, 50 fixed, what that would have done to the $40 or roughly $40, it would have brought it down by about $3.30. And if I then carry forward and look at where you currently are for 2020 at 30,000, 887, and if you did get an increase of 3,000, that would be a reduction from 42 down to 40.14. If you got 6,000, we would reduce by almost $4.00. So the tough part is I get that you're having less of your, but part of Vermont's is a variable piece. And so as we have more membership and you have more, you're collecting those $42 across all those members and the number increases, you not only contribute more to cover the fixed, you don't need as much on the variable piece or you don't need as much on the fixed. So I'm just trying to say, how do we come to terms with the fact that we keep increasing and we're not really getting those benefits because of some of the assumptions you have in for what membership would be? Yeah, so I guess I would think well, the variable is generally the same on a per-member, per-month basis. I think it's under the fixed, there's two levels of the fixed. There's the enterprise-wide fixed versus potentially the NBPE Vermont specific fixed. So we have an office in Vermont that would be a fixed expense. Obviously that as we grow more in Vermont membership, that should go down over time. But the enterprise-wide fixed expense is something that I would have to ask the financial team to be able to break that out of that level of detail. But I think that's the way I would think about it. To the extent that we are growing our membership in Vermont, the Vermont fixed piece, I agree, would go down. But the variable, I think in my opinion, would stay flat. And then the fixed enterprise-wide is something that is another one that is dependent on our overall enterprise-wide membership. Because we keep running into, you know, we're going up in membership. I understand it on a number. I can please, I can fully understand that. A question on page 66, to look at the price and trend assumptions that we're going to have on page 66. And when you look at the leverage of impact and when you look at, you know, the alliances and then how co-pays and deductibles end up reducing that amount to come up to what you get, what you get paid. When we looked at the deductible piece, in 2020, we were looking at $60.21. And last year it was $56.27. So about a $4 difference for a year, about $48. And how does that then correspond to, if I look at the change year over year for deductibles and maximum out-of-pocket? So for Silver, for instance, the deductible is going up by $400. The maximum out-of-pocket is $200. Bronze, it's $300, $300. Gold, it's $5,300 and the platinum's pretty low. And yet the reduction is only $48. So it just seems, you know, consumers are paying a lot more out-of-pocket or for their deductibles or maximum out-of-pocket, right? And yet when it translates back, it's only a $4 offset. So I mean, how do we look at that relationship? Because each year it just creeps up slowly and that's one of the big things. Will there be consumers about how much more they're paying? Yeah, I'm not sure I fully understand the question, but let me just try to answer the way I interpret it. I believe what you're asking is about how our benefits are changing year over year and that the deductibles may be increasing or decreasing. The adjustment in the deductible column on page 66 that you're referencing, that is reflective of 2018 services when we develop our planned level premium rates. Those, those actuarial values, the pricing actuarial values that we develop capture the impact of deductibles and out-of-pocket impact. So this figure right here is based purely on what happened in the 2018 experience period projected forward. And that said, we are enrolling members and leaner benefits. So as that, as we're enrolling members and leaner benefits, those are generally plans that have higher deductibles. So to look at last year's figure and identify what the changes from last year this year, I think it should also be measured against a change in the average deductible that members are seeking. I think that's what I was trying to do. I would say this change was $50 roughly, right? So basically you're saying it's a $50 impact year over year but the deductibles are going up by $300 or $400. So it's just, it seems like more of that shift is shifting to the consumer that you're not offsetting all of that here. And I understand it wouldn't be a one-for-one because everybody doesn't use that but they just wanted to go early, you know, that $50 purchase. Well, if a benefit is changing, say there was a $1,500 deductible in 2019 and then in 2020 there was a $2,000 deductible, the value of that $500 increase in deductible is being passed on in the recent increases that we have in the premiums that we're offering. So if we were to go to, I believe this is the age 73, the long table of all the premiums, there's a column that says benefit actuarial value. It is one, two, three, four, five, six, seven columns in. That benefit actuarial value is capturing the impact of any benefit changes that are taking place. So there is a premium offset that is implicitly included that you're going to price it back that a member would have to pay for it at the pocket. Yep, bad debt. And the 0.4, that's quite a bit higher than what's to be looked for by your other major competitor in the marketplace. And just, you know, it's double. So looking at a 0.4 percent, a couple things. One is you're talking specifically about consumers who do pay for premiums and then have claims against those. Is there any way for you to marry those up in some fashion? So, you know, if I'm not paying my premium and then I'm getting, you know, I'm able to collect claims and have claims paid, you know, it seems like you'd be able to leverage that against that consumer. I'm not an expert on the policy, but there is a grace period that exists where even if a member doesn't pay their premium, we do have to cover their claims. And there is, to the best of my knowledge, there is any recourse that we can take to the extent that a member has exceeded the grace period and isn't paying their premiums. Then that's where we will intervene and do a review to ensure that we're not driving up costs unnecessarily for members that are actually paying their premiums. So, within the grace period, there isn't any recourse that we can take for those members. For fraud and waste, you know, how much do you actually collect on fraud and waste? And do you guys have a estimate of what you think is out there for fraud and waste? I have never gotten an exact figure of that and did have a conversation with our SIU lead on last week just discussing some of the programs that they, from place they are doing. They've improved the staff, they've increased the staffing and they've actually, through that, done a lot more analytics and data mining. So they're trying to identify the regular practice pattern to work fraud or waste may exist in the system. To put an actual number on what they estimate as a percent and your total dollar amount, that wasn't something that we discussed. But I do know that we are increasing our efforts to try to proactively identify what are some of the items that we can address before it actually gets into a litigation case or having to address it after the fact so we can set up our systems to automatically identify some of these regular patterns to keep more proactive about it. So you don't have a percentage of what the estimate might be? I do not. We talked about the cost savings and then gave some sort of examples of telemedicine and things like that. How much do you think these have benefited year over year? I remember you speaking to me like the cost impact. So while utilization is increasing, substantially when you look at telemedicine in isolation, it's a very small percent of our overall utilization. To the extent that there's growth, we will capture that in our refinements in the telemedicine benefit. But it isn't enough to really move the needle at this point. I would just, I advocate for it. I think it's a really effective tool to utilize. But I think there's a lot of education that goes along with that. Well, we've identified, we've analyzed segments of our population and who's actually utilizing telemedicine benefit the most. And what we've identified is that self-insured clients that we have are utilizing telemedicine more than large employers, but they're utilizing it more than the small groups and the individual employers. And the reason why we think ASO clients or self-insured clients are utilizing those benefits is because there's a direct cost that the client is experiencing. So they recognize that there is a savings opportunity that exists and they're putting a lot more marketing materials forth, a lot more member education or employee education to utilize those benefits. We do try to educate members on that benefit through our member welcome packet or on our website. But there isn't a way for us to just kind of pick up the phone and call people directly and tell them you should utilize telemedicine benefit in this instance outside of potentially whether we have those programs in place like the ER, the high-utilizer of the ER program program. But do you invent anything within work cost in the beginning, whether that is moving people out of the ER into a partner care specialist? What we're capturing right now is the experience that we've had in 2018. Our utilization trends were volatile so we don't have a utilization trend and we're not building in anything for additional utilization of something like telemedicine or reduction in ER. And then looking at the L&E recommendations, several of them because there's new information that we have, whether the risk adjustment, things like that. But on the medical utilization, which the bulls used to be released by like 5% of the breed, so what would happen if Melanie didn't find that? We would have continued with operating under the assumption that we didn't have enough data to quantify what we, a utilization trend of maybe other than 0%. Now because utilization trend is skinning the entire market and providing practice patterns, it is helpful for L&E to have the entire market scan and actually be able to analyze both competitors' data to provide an estimate because we do think that is a more appropriate approach to quantify utilization trends. I do have a lot of question on confidential information so how do you think of that? So this is a public meeting we're going to have to go into in the next session. Or can I refer to it and not say the numbers or? I love the question calls for those numbers. Which document we're talking about? I'm talking about tab three. After chair finishes this question, before we take it away, do we direct and then take break? Okay. Is that it? Yeah. I would rather take a break after the board finishes, please. It's been a long morning. I'm going to take a break now. Stay with the question after that. Does that work? No. I don't think so. Just a half. So we'll recess to be back in 10 minutes.