 Good afternoon everyone my name is Kevin Mullen chair of the board and I'll call this meeting to order and we'll start with the executive director's report Susan Barrett. Good good afternoon and thank you Mr. Chair. A few announcements a couple of upcoming off-cycle meetings so they're not on Wednesdays. For this Friday at 1 p.m. we will be hearing from the NORC from the University of Chicago team who did the federal evaluation of the Vermont's all-payer model for the first two years. Again that starts at 1 p.m. and then additionally on Monday November 8th starting at 8 30 a.m. we will hear Springfield Vermont hospitals revised FY 21 budget with a potential vote. In addition we have a couple of public comment periods that I will remind folks about. The first is the FY 22 one care Vermont but ACO budget and we are accepting public comments until December 1st. We accept public comments every day but in order for them to be considered by the board and staff please get them in by December 1st and then we have our ongoing public comment on a potential next agreement with the federal government for an all-payer model. We are sharing those with our partners at AHS and the governor's office as they are leading the negotiations and that is all I have to report out. I'll turn it back to you Mr. Chair. Thank you Susan Abigail could you tell me what the date of the the last minutes are? October 27th. Great so next on the agenda are the minutes of Wednesday October 27th. Is there a motion? It's been moved by Tom and seconded by Jess to approve the minutes of Wednesday October 27th without any additions deletions or corrections. Is there any discussion? Hearing none all those in favor of the motion please signify by saying aye. Aye. Any opposed signify by saying nay. But the record show that the motion carried unanimously. So at this point I'm going to turn the meeting over to Christina McLaughlin who will tee up our conversation on the healthcare workforce strategic development plan so Christina. Thank you Chair Mullen. Hello everyone my name is Christina McLaughlin I'm a health policy analyst here at the Green Mountain Care Board and I have been supporting the board's work and review in the draft healthcare workforce strategic plan. I'm going to share my screen soon these slides are posted to our website under today's board meeting date if folks are interested in having them. So just give me one minute. Can everyone see my screen? We can. Perfect so today we are here to just review quickly the draft healthcare workforce strategic plan language and statute and the feedback that the board received during its review. So with that just a quick review of Act 155 of 2020 which is the language that changed the current statute of the healthcare workforce strategic plan and directed the director of healthcare reform to maintain a current workforce development strategic plan that continues efforts to ensure that Vermont has the healthcare workforce needed to provide care to all Vermont residents and maintaining the plan the director or designee shall to consult with an advisory group composed of the 11 following members and it was noted that at least one has to be a nurse to develop and maintain the strategic plan and you'll see the 11 members listed there which includes the a rep from the Green Mountain Care Board's primary care advisory group someone from the Vermont State College is from a heck from an FQHC Vermont hospitals, a representative of physicians, a representative mental health professionals of dentists, naturopathic physicians, home health agencies and lastly a representative of long term care facilities and is also noted in Act 155 that the director or designee is to serve as the chair as this advisory group. Act 155 of 2020 also notes that the director of healthcare reform shall ensure that the strategic plan includes recommendations and recommendations on how to develop Vermont's healthcare workforce including the three items listed below. So the first is the current capacity and capacity issues of the healthcare workforce and delivery system in Vermont including the shortages of healthcare professionals, specialty practice areas that regularly face shortages of qualified healthcare professionals, issues with geographic access to services and unmet healthcare needs of Vermonters. Second is how a state government universities and colleges, the state's educational system entities providing education and training programs related to healthcare workforce and others may develop the resources in the healthcare workforce and delivery system to educate, recruit and retain healthcare professionals to achieve Vermont's healthcare reform principles and purposes and finally to also assess the availability of state and federal funds for healthcare workforce development. The original Act 155 language included an earlier date for this past summer but given the impact of COVID-19, the dates were revised in 2021 per Act 74 which was the budget bill to delay the submission of the draft plan to the board and consequently also the submission date to the legislature to allow for more time. So the draft plan was submitted to the Greenmount Care Board. In this case on October 15th and the board has to review and approve within 30 days following receipt and then honor before December 1st the director then is to provide the updated plan to the House Committee on Appropriations, House Healthcare, House Commerce and Economic Development and the Senate Committee's on Appropriations, Health and Welfare and Economic Development and Housing, Economic Development Housing and General Affairs. So just quickly to review the board's review timeline. We received the draft plan as I mentioned on October 15th which was a Friday and at that time we did post and share the draft plan with interested parties and stakeholders and posted to our website and that is when the special comment period began. The following Wednesday on October 20th is when the director of healthcare reform, Ina Bacchus presented the draft plan to the board and a public meeting where we took public comment and the board discussed the draft plan. Then the following Monday the board met with the general advisory committee and they provided feedback on the draft plan and in preparation that group had received the draft plan and information related to the 10-20 board meeting and then we ended the special comment period on November 1st to allow for time for the board to review any public comments that were submitted before today's meeting. Here we are today on November 3rd so the board can discuss and potentially vote on the draft plan. We did tweak the timeline a bit to allow for the board to vote on the more finalized version of the draft plan later on. So we will be receiving on Monday November 8th an updated draft plan to the board which will be posted to our website once we receive it and then after that we have added a final vote on the draft plan for November 10th and that I believe is happening at the end of the day on November 10th but we will update the press release and agenda accordingly. So with that part of the board's review process included as I said feedback from our general advisory committee. And I noted here this is a very brief summary of what was proposed during the two-hour meeting on the 25th of October and I'll just quickly run through these so that folks who are on the phone or for folks who are interested. So the first part of the feedback was to include representation from all state nursing programs a member of the public and more practicing nurses in general to the state interagency task team. Second to include nursing faculty and scholarship and loan repayment programs specifically incentivize sites agencies and preceptors to take UVM Medical Center and in-state students. D includes specific language and programs to address retention to prioritize retaining our current workforce. E was to look into 6 to 12 month onboarding programs for APRN residents. Currently we do not have those for APRNs in the state of Vermont. F other than pay look at how to retain our current nursing workforce. There was an example put out during our general advisory committee meeting that joint appointments between academic nursing programs and facilities would be a good example as to how to keep our nurses without just paying them more. G is created a formal process of exit interviews to find out why they they meaning the workforce are leaving their job to help address retention issues. Increase the number of ultrasonautographers diagnostic imaging service and echocardiographers as they are in high demand. It was noted that when these services or positions aren't available create access issues and burden issues in our workforce. I is to train higher levels of workforce other than doctors and de specifically it was noted that an associate's degree in physical therapy is very valuable in an office setting to get work done. But Vermont does not specifically have a PT program offering associate's degree in that field and then higher change management experts and support hospital leaders to utilize executive training programs to improve leadership and work environment. And finally investigate if we are using current staff effectively and why nurses are retiring early. This obviously was part of a much larger discussion and if folks are interested there are some notes on this meeting on our website and we do have a video teams recording of that meeting if folks would like to know more. As I mentioned we also held a special comment period from October 15th through November 1st. During that special comment period we received six public comments in total for which are posted to the website. We did receive one after the deadline which is also posted to the website. So there are now five on that public comment page on our Green Mountain Care Board website. Just to summarize the public comments that we received in writing. I added a list of bullets here which include adding the UVM College of Nursing and Health Sciences to the list of entities to act on education and training recommendations. Add critical access hospitals and employees of FQHCs to funding and tuition reimbursement list. Third to address issues with consultation notes sent to private primary care providers. It was noted that this can worsen care and contribute to burnout. Increased scholarship and loan forgiveness dollars so not only extend those programs but to increase the amount of money put into them. Create incentives to further education so scholarships for graduate degrees and increase mentorship and job support overall. Increase housing to help recruit and retain Vermont workers. That was that was actually mentioned specifically in the report as well but folks did support that. Promote and fund more training for PAs and PEs and nurses and provide adequate pay and benefits and increase staff at treatment centers. So again while this is a summary the special comment period comments that we received are posted to the website that we were that were granted for us to post. And with that I included a slide with the resources which includes the two acts Act 155 and Act 74 that I mentioned. A draft of the health care workforce strategic plan. I also included a link to the 10-20 board meeting presentation as well as our general advisory committee meeting page in case folks would like to see those notes and related materials. And then finally a link to the public comments that we've posted to our website. And then with that I will turn it over to Chair Mullen so we can move to board discussion or public comment at this point. So I will say that I originally had hoped to have a vote on this today but because of the volume of public comment and the fact that at the last discussion that we had as a board with the director of health care reform one of the things that she felt was important to put in and I can't remember if it was Jessie who suggested or who but it was the breakdown between short-term mid-term and long-term strategies. And my understanding Christina is she will have that to us by Monday. Yes that will be incorporated in the updated version submitted by the end of the day on Monday. So it would be much better for us to devote on a more final version of this plan than to vote on something with a bunch of suggestions that may or may not already be being incorporated. So that's why I don't think we're going to be voting today but certainly the other board members could correct me. So with that I'll turn it over to board members for comments and questions. Well I'll go ahead and start. It makes sense to me to hold the vote until we see the revised plan because that would also give the director of health care reform some time to think about how she might be able to incorporate some of the comments that we received. Some of which may be. And many of which were already in there too by the way. Yeah. I just want to point out that a lot of the comments were in there. Yes. So I think having that information be clear would be helpful. I overall I would say I liked Jess's suggestion of incorporating sort of short medium long term initiatives that dovetails with my thought that I do think we having some sort of timeline or timeframe is needs to be incorporated into the report so I think that meets that need. I would like to put out there that I think it would be good for us as a board to get periodic updates because I think that one of the challenges of course with an inter with this kind of topic is it spread throughout state government. Different parts of state government have different pieces of the workforce at least on the government side sort of the workforce initiatives. And so I like the idea of the task force but I worry about the urgency getting lost. And so I think one way that we can help keep people's feet to the fire is to ask for public updates so that we can hear how that's going. So that was something I wanted to throw out for people to think about. What's the time interview that you're thinking about Robin? Is it bi-monthly quarterly? What would be the time period? Because I think you've got a very valuable point that we offer a forum where people can hear in an open manner exactly what has happened, what hasn't happened and hold people's feet to the fire. So the question really is what is the appropriate time period? I think that is the key question and I guess my one thing I would wonder is it wasn't necessarily clear to me and maybe it was clear in the report and I am not recalling it, how often the state interagency task team would be meeting. And so certainly I think our updates would need to be tied to the frequency of the activities. But so not knowing that I'm not sure but I was thinking maybe just to start quarterly and then once the ball is kind of rolling we could potentially roll back that frequency but not knowing whether that agency would be meeting monthly or bi-monthly or whatever, I'm not exactly sure. I actually think bi-monthly might be better in the beginning and then we could make it longer but that's just where I'm thinking initially but. Yeah, and again, I don't, my goal as I said is to just make sure that there's some transparency and we're really pushing folks across state government to keep this issue highlighted given the importance of it. I do think one of the tricky things that was reflected in some of the comments is the balancing the clinician representation which I think would actually probably be on the advisory group. It looked to me like the interagency task team is meant to be state government officials to coordinate across state government and prioritize existing state initiatives or the creation of new state initiatives. Whereas the advisory group which is in statute is the appropriate place to have the state broader stakeholder representation. And I guess my, I don't know that this needs to be added to the plan but like my thought on that is to try and be a little fluid with the advisory group. So if you are really focusing on nursing issues, bring in like create a little subgroup on nursing issues and bring in more representation. I think otherwise an advisory group that gets much bigger than 11 becomes tough to actually get anything done in because it becomes too big. I don't, again, I'm just saying that as a suggestion I don't really expect that necessarily to be spelled out in the report. The other area that really stood out to me is we did get a public comment and this is actually a recurring theme that I think we've heard in other areas about the limitations in Medicare around mental health and substance use disorder provider types. So I'm gonna, I'll just say out loud that I'm gonna file that away in the back of my mind as something we should think about when the administration comes forward with their proposal around APM 2.0 because that's something that could potentially be folded in. So I think that's just something for us to keep in mind. So those were my initial thoughts. Other people's thoughts may spark more from me but I'll let other people speak. That's great Robin, thank you. Maybe I'll go because I can build a little bit off of some of the comments Robin made and you made Kevin. So first of all, I mean, I thought it was a pretty comprehensive report and I appreciated the work that Ina Bacchus and the advisory group did. I agree that I'd like to see more accountability at least made more explicit in this plan. I had thought in my head and my notes that the interagency task force should be required to submit quarterly reports on their progress, on the timeline, on milestones, how they're planning to judge success. And I think having the report presented in a public setting, I think makes a lot of sense. This is an urgent issue affecting the entire state and I think the transparency on the progress would be important. I hadn't thought about until you just mentioned at the frequency of their meetings but I actually think that should be included in the plan. So I would add that as something that the director of healthcare reform should maybe consider putting in there explicitly, how frequently she and the advisory group think that this interagency should meet. My preference would be a lot in the beginning as we have, this is a critical issue. So once a week, every other week in the beginning to get this off the ground, I think is important. If they're meeting once a month, it's gonna just take that much longer to implement the recommendations. And I'm glad to hear that there's gonna be an incorporation of the short-term, medium-term and long-term recommendations. I think that will help prioritize but I also think it will be helpful if one of the first tasks of that interagency task force should be, even within that, to start prioritizing based on evidence of effectiveness, based on resource needs and based on operational efficiency or feasibility, rather. I think in some sense doing a cost-benefit analysis, I know I'm sounding like an economist here, but the return on investment of a dollar spent on loan repayment is not the same, may not be the same as a dollar spent on scholarships, may not be the same as a dollar spent on preceptors. And we have scarce resources here. We have a big problem. So I would like to see that interagency task force really thinking about how to prioritize along those kinds of dimensions. And then I think around, there were some small considerations I wanted to throw out there for comment, but in their demand and supply analysis, which I think is a good idea to really understand where there's unmet need. I think, and I mentioned this in the meeting last week, but having that licensing census data, which is mentioned in the report, I would like to see it include a question on whether the provider is actively practicing in Vermont, part-time or full-time. If we really want to understand supply, we have to understand who's actively practicing and at what level they're practicing, meaning 20 hours a week, 40 hours a week, something like that. That's how you're gonna get a handle on supply. So I think that's a recommendation that could be made to OPR. And then on the demand side, I think we're gonna need a better understanding of wait times. And I think to the degree that we're trying to collect demand and excess demand or unmet need, we need better ways to understand wait times on a consistent basis and on a uniform basis. So I would maybe mention that as well as something to consider. And then the last point I wanted to make was, I would love to see the plan put greater emphasis on K-12. So on that K-12 pipeline, and this is something that Kevin, you talk about all the time, we have to grow our own. Most of the report emphasis is on the college post-secondary training. And K-12 is actually largely relegated to future considerations in the back of the report. And I think the reference, really the reference to anything K-12 is that there should be a recommendation that we make middle students aware of careers in the healthcare sector. I guess I would just say, I don't think that's enough. I think we need more than that. And I think it needs to be front and center, not in future considerations. I think it needs to be in now considerations. I would love to see the agency of education working with high schools, working with tech centers and career centers now to help create clearer pathways for high school students to the healthcare sector, more training in high school, internship opportunities, you know, high school curricula that actually prepare students for careers in healthcare, bio courses that are designed for healthcare workers, training for guidance counselors to identify students with early interests in healthcare. I think we need to start recruiting early. And I would love to see that part of the report pulled up into the meat of it, not a future consideration. I tend to think this may be one of the lower resource, higher impact, higher feasibility, types of recommendations that could be done in state. So I may be wrong on that, but I would like to, you know, hear some feedback, I suppose, from others on that. And then I guess the other thing, you know, there were some pretty good comments that we received. And so to your point, Kevin, about not voting today, I would love to hear feedback from the director of healthcare reform on some of those recommendations, because I think some of them were quite good, helpful. And, you know, to hear whether or not they make the final cut or not from the director of healthcare reform. And if they don't, why? They don't make the final cut would be helpful. And I agree with you, some of them are already in there, but I'm talking about those that are new recommendations. So those are my thoughts. Thanks, Jess. Tom? Well, let me add to the pile. I'm listening to Robin and Jess and you. And, you know, I think we're all kind of thinking in the same direction. And it's just how to get from where we are to where we want to go. And that is the thing that worries me the most. That, you know, I agree that the plan that Enos presented to us was a comprehensive list, pretty much a comprehensive list of some good ideas. And it was improved by our advisory committee. I thought that that discussion was a very helpful and energetic discussion. And I also think that some of the written comments, especially there's one comment that where the comment or didn't want it to go public, which I thought was a, and I don't know if it's okay for me to say that, but I thought it was an excellent insightful comment from somebody who is on the ground and kind of looking up at us as to what we're doing. So the, you know, as I said at the end of the last meeting on this, there were five shells and only, and 73 shoulds in the state workforce plan. And what I worry about is that we have this effort focused on workforce, but there's so much else that's going on that is related and, you know, to this effort that I worry that somehow, you know, if this effort can be embedded in a group of people that have kind of a larger view of stuff, I mean, I see that their report to establish a state interagency task force, obviously, you know, that's needed, but it's just combined, you know, comprised of six people, you know, from state government. And then to integrate it with the State Workforce Development Board, I'm not quite sure what value added that is given, you know, I would think that might take quite a bit of time and it would be nice to be integrated with the State Workforce Development Board, but I'm not quite sure what that does for healthcare, specifically given the magnitude of the issues before us. So, you know, and I also worry about this unfolding in the context of other moving parts that are also at play, that aren't settled, but they're at play. And those that would include the wait times task force, the all-payer model renewal, the sustainable ability effort and the burns and BRG suggestions, the ACO budget, which we'll have next week, the benchmark plan review, which is due to the legislature on January 15th. And, you know, I'm kind of looking at that, thinking about, well, where is all the money gonna come from or where are the efficiencies gonna come from to pay for it? I mean, there's two ways to pay for it. And I just am not sure that this state interagency task force, whether the report quarterly or monthly, is big enough to kind of allow this project to unfold in the context of an awareness of what else is going on across government in these other efforts. So, you know, I would be open to suggesting that this, I mean, we don't want a big group that's unwieldy, but this is six people. If this were 10 or 11 people, you know, with a few others from kind of outside the workforce issue, whether it's the commissioner of DFR who is gonna lead the charge on the benchmark plan or if it's maybe a couple of legislators or the hospital association, you know, just trying to get it to a size where the discussion is robust and the focus is workforce, but it's done in a context of people around the table who collectively are aware of things going on elsewhere. You know, I look at the state budget, something obviously I haven't interest in. And I'm thinking, well, you know, Diva ended their year with, you know, in terms of their Medicaid programs with the $16 million underspend. The state general fund now is $28 million ahead of target through the end of the last month. And, you know, these are resources that other people are gonna be competing for, you know, outside of workforce. So as much as we could keep the task force reasonable in terms of the number of people, but allow it to have folks on it that can offer insights to what else is going on in other areas related to the workforce, I would think would be helpful. That was my big concern is the coordination on this is essential. And even within the workforce plans, there's some of those things are gonna have to be thrown overboard. You know, it's just, we can't do everything for everybody. But I worry that the task force is in this corner and there are other areas that actually could be helpful to the task force that are just off the screen of the task force because there's nobody on it that is engaged with the state fiscal affairs or DFR and insurance companies, et cetera. So that's my take on it. I thought it was, you know, did a great job. I think the commenters have been a great job. It's been a, you know, a very positive experience to see people supporting something and trying to make it better. But I worry that it's just, it's not gonna get lost. Definitely it will not get lost, but that it's gonna be diminished in the context of all the other things that are going on. I think all valid points and something that we all should be very concerned about with there's a limited amount of resources and how they get allocated. As we know, there's a lot of competition for that allocation and the encouraging thing that I think that we're at a point in time where everybody's rowing in the right direction. When you hear the governor and our US senators and our legislative leaders all talking in support of shoring up the healthcare workforce, then I think this is an opportunity. It's a rare opportunity for us to make some progress. And it's a little later than I would like for that progress to be made, but you have to start sometime. So now's that time. Well, you've been very good on this, Kevin. And when I walked into that Kasselton meeting and I was late because I got a little bit lost, you know, the topic of that meeting was workforce. And it was a fascinating eye-opening meeting for me where you have somebody standing in front of the room at that point in time, saying that we're gonna be 1900 nurses short in X number of years. And here we are down the road X number of years and it's worse than imagined. Yep. Any other comments from board members before I open it up to the public for public comment? So I would just jump back in and say I really like Jess's suggestion of some sort of prioritization because I think to the point that Tom made and you, Kevin, as well as Jess that it's a very long list and not everything is gonna get prioritized. And I would rather see a shorter list of things get done than the long list slowly moving forward potentially but not actually getting a call, not really having things move. So I think having something that clearly states who is going to prioritize the items by what date would be good. And I'd like the idea of trying to come up with, I mean, there's no dollars in the report. Like you can tell the things that are gonna cost money but are they small money or big money? Some of them could be as big or small as you choose, right? Like with loan forgiveness and that sort of thing you could fund it a little or you could fund it a lot. There probably is a right amount in there that we should be targeting but we don't really know that yet. So I think having something clear in the plan that talks about prioritization and coming up with dollar estimates so that you can realistically try and figure out what makes sense to move forward with is important. So I agree with what everyone else has been saying. Okay, anything else from the board? If not, I'll open it up for public comment. Any member of the public who wishes to comment you can either raise your hand in teams or if you're calling in, you could just speak up. So does anybody wish to comment at this time? And I do see a hand raised, let me get to there. And the hand is from Dale Hackett, Dale. Yes, I just wanted to make a quick comment that a shorter list, I can see where that would be helpful but the items on the shorter list would need to be synchronized in such a way like if you're gonna have long forgiveness, you still have to have a college though that they were able to attend to get the education in the first place. I'm just using that as an example to try to say that the shorter the list gets, you're still gonna have synchronicity, otherwise it's very fragmented and what would the return be if we're too fragmented? That's all. Great points, Dale, and we will not have success if we do not expand the educational opportunities for Vermonters. Is there other public comment? Next I'll go to Walter Carpenter. Walter, how are ya? Hey, Kevin, not too bad. Sitting here watching the rainfall and the sun come out, facing the windows while I've got the hat on. I'm waiting for the snow. I agree with Dale, I actually agree with everyone else on the board about the list, the items on the list being a whole lot. Dale made a good point on the education, which I hadn't thought of, so thanks to Dale for that one. Again, I repeat once more pay benefits, workforce burnout, in other words, don't short-staff your staffing on the hospital levels. And I know I didn't really see that on Ena's report, but when you're on the ground, that's the big cause of it. But again, I think a list, Robin's idea about the board was one I agreed with, but if they're gonna study it, have perhaps more or make it not too unwieldy and so you can at least get something down. That was a good idea. I'll shut up for now, Kevin. Thanks, Walter. Dale, I see your hands raised again. Did you have another comment? No, I guess it just didn't go down. Can somebody shut it off? Cause it doesn't say on on my end. Okay, it's off on my end now. So somebody took care of it. Is there any other public comment? And next I'll go to Rick Dooley. Rick, how are you? I'm good, thanks. I appreciate the report and the certainly the emphasis on workforce. One thing I just wanted to sort of bring to the attention is that one of the ways that independent folks have been able to recruit provider to the state has been through the Green Mountain Surgery Center. There are, I know we had a pretty robust conversation at the advisory committee about, you know, some employers are not prepped coveted as employers and that some of the bigger institutions sometimes struggle with that. And for a lot of providers moving into the state, that's an issue and they don't necessarily want to work for a big, huge hospital. But having some of that autonomy that comes with an independent practice and an independent place to do their surgeries or procedures makes a huge difference. So that's something that I don't know that I saw it called out specifically in the report was something I just want to sort of draw attention to that certainly supporting independent practices and independent surgery centers may help retain some of the providers we're looking for. Thank you. Thank you, Rick. Is there other public comment? Other public comment? Hearing none, we'll come back to this conversation next week. And we look forward to getting the revised draft from Ina Bacchus. And again, I applaud her tremendous efforts and those of her group that's worked with her throughout this process and we're getting there. So. Kevin, just a process question. Will the comments and discussion today from the board be sent over to Ina Bacchus for potential incorporation? Is that how it's gonna work? And then we'll get. So Christina is going to send that over to Ina and so I'm sure that Christina took great notes. Great. Thank you. I'm reading seriously. I have all my notes. And she does a great job of getting them to succinct bullets too, which I truly appreciate. Okay. With that, we'll move away from this discussion and is there any old business to come before the board? So Kevin, I was hoping that we might just have a process conversation and follow up to our discussion last week. That'd be great. Okay. So I'll go ahead and kick it off if you want unless you. Go for it. Okay. So I just wanted to... So it was great to get the tons of information that we got last week and just personally in thinking and mulling of the last week about it, I think it would be important for us to at a future board meeting have more of a discussion around next steps and where we see ourselves and maybe even suggestions for others. Taking the information and moving forward as well as certainly there were some suggestions around potential future areas of analysis we might consider. So obviously the issue of hospital sustainability is much bigger than just us. We're not gonna be able to fix all of the issues with the current regulatory system that's in place and our current boundaries of authority certainly. And it's gonna need engagement with legislators at the community level, hospital boards of directors. So I do think it would be great if we could plan on having a scheduled discussion in terms of our takeaways and what potential next steps might be. I think it's an excellent suggestion Robin and we will work to try to figure out a date when we can next bring it back to the board. We've got a few things coming up but I'm sure that we can fit this in and make that work. If I could just add to that and I really appreciate thank you Robin for bringing this up today. I do think this is the start of a much longer conversation. And I'm just wondering if our staff might also weigh in at some point in those conversations. For example, the data analysis used 2009-19 data, right? That was the baseline. It's a first pass at it for obvious reasons 2020 and 2021 were unique in their own way. And I guess I would love to hear from the data analytics team about what they took away from the data that was provided. What could they do going forward? How do we use data in the future in our regulatory processes? This was enlightening data to be sure. So how should data like this better inform our hospital budget process, our rate review process, our ACO process? So I'd love to hear from those teams how they are absorbing the information and thinking about the regulatory processes that they lead. And I also think part of the future conversation should be how do we take this information and how does it inform our next agreement with the federal government? So those are the areas that I think need further conversation with some help from staff too, to hear what they thought. All of that data might better make our decision process better and make our next agreement with the federal government better. I think that's a great point, Jess. I think in thinking about the APM, I know there was some of the comments that we sort of heard about or saw in the press. There was, I think people were wondering why you would look back to fee for service when thinking about value-based payment. But of course, you need to know where you start and where you are and what the issues are with where you are in order to redesign those payment models. So I think that having this base understanding will be really important because there certainly tends to be a focus at the federal government and cost containment. And we certainly know that affordability of commercial insurance is vitally important. We've seen the degradation in our small group and commercial marketplace over time. I think the question then is how do we balance that and still ensure that Vermonters get the services that they need where they need them? And that's the really hard balancing act. But I think it needs to be part of the conversation with the federal government. So Susan, if you could work with staff to try to put that board meeting together, that would be appreciated. Okay, is there any other old business to come before the board? Is there any new business to come before the board? Is there a motion to adjourn? So moved. Second. It's been moved and seconded to adjourn. All those in favor of the motion signify by saying aye. Aye. Aye. Any opposed signify by saying nay. So have a great rest of the day everyone. Thank you. And Robin, we were wondering if you're getting an endorsement stipend from TD Bank. Oh yeah, I didn't even realize their name was there. Nope. Just like the Valentine Day banded cheeriness. Maybe it's time to change the background. Okay, have a great day everyone. Bye. Bye bye.