What's up everybody, I'm the Mangus, you are awesome and I'm kinda infamous for my deep burning hatred of Morgash and Revenant. However, I don't actually hate either hero, both of them have a really cool design with interesting kits. Either hero would make a great addition to any of the Paragon projects if they're introduced correctly, and therein lies the source of my hatred. The way Epic added them into Paragon.  Epic knew that both heroes had insanely overscaled kits, but instead of balancing the mana costs or power level of the abilities, they decided to give them handicaps. For example, in Morgash's overview, they really stressed her short range. Morgash is a close range caster, so positioning is very important. But if you try to get too close, it could result in your death. That was her handicap. Morg had a very low mana cost, dealt a significant amount of damage, locked onto your target and could pass through terrain, but it didn't have the same range as Howitzer's R2000 rocket.  It still had decent range and the rest of her kit allowed you to run up, face in the general direction of your target, mark them, and then just swarm back through the minions to regain any lost health. You didn't even have to keep doing it, once they were marked, that was it.  Of course that's not how you actually played. The ability was so easy to hit, the handicap just wasn't really there, so why not just mark people on cooldown and finish the job faster? Epic did eventually raise the mana cost and lower the damage, but by then the damage to my psyche was already done. I think a good way for any of these projects to introduce her without gimping her powers is to just make Mark a projectile skillshot. That way having to run up to your target a little would come at the risk that you may actually miss. A projectile also would be able to pass through terrain and could be blocked by Steel's shield. I would also like to see some kind of duration on her mark. Shinbi had to really plan out her ultimate usage because her wolf stacks didn't stay and I found that to be much more fun than just waiting until you see the person you marked get low enough to ult. That may take too much away from the essence of Morrigan, so I'm not 100% on board with that idea, but Mark really does need to be a projectile.  And then we have Revenant, an ADC with two lock-on abilities. His E called Scar didn't do much on its own, but it could be combed with Obliterate, which was an already stupidly high damage ability. What handicap did he have? Obliterate could choose targets randomly, meaning that you could counter it by standing with minions or another hero to split the damage.  It wasn't that hard to single someone out with Obliterate. Now, some Revenant players went with the Crypt build and relied on their basic attacks for damage, and I respect that. It was the power-stacking Hail Mary Revenants that got on my nerves.  It didn't matter that I sucked asset-lending basic attacks, I could just Obliterate, which is why I stopped playing Revenant. It didn't feel good to me to miss all my shots and then just combo two lock-ons for a kill. I know it certainly didn't feel good for enemy carries to lose a fight to someone who obviously couldn't aim as well as they could. If you went with the ability build on Rev, the only time it mattered that you could land basics is if you were against another ability damage Rev. Is there a way to fix Obliterate while retaining the ability's flavor? I'm not sure. I suppose you could just decrease the damage, but that seems like a bit of a cop-out. Obliterate is an awesome ability with a wickedly cool animation that can only really work if the individual projectiles track, so I would be sad to see it change too much.  So there you have it, folks. I don't really hate Morrigation Revenant. I just hate handicap-based balancing. I know a lot of you get pissed when I rag on those two heroes, so I hope you now understand where I'm coming from. If you guys have your own suggestions for how you think either hero should be changed, please let me know in the comments below.  If you enjoyed the video, please hit that like button. But for now, this is the man-goo signing off. You guys have a good one. Man-goo!


Hey you guys so it is Tuesday and I'm responding to some Fulery Christine sent me Chow she sent me this hundred page pd of document we're supposed to read about modern workplace learning in 2018 is 170 pages. Speaking of reading you guys I was trying to say a couple of logs ago that one of my classmates has said that her goal for reading books she had set a goal last year to read something like 80 books why did she say she read like 130 books in one year. I am a reader I love to read books but I mostly was reading before I had a child and I wasn't too busy so that that was like two or three weeks ago right I'm like how could she read all of those dang on books and I'm a fast reader I can sit down and read a book in three or four hours yeah I'm a fast reader miss Jackson can read like that so it's not like I'm a slow reading it takes me I just don't have the time that was three weeks ago right so I'm like okay let me see what I have in my candle cuz I do have a couple of books like if there's a book that someone has suggested or that I need something on need help on or something I will download a book and I read it but I love physical books I have a little mini library of about between JB and us we have about a hundred books to be quite honest we have about a hundred books but I love books I love to be able to snow books and to flip through the pages so excuse me I have a lot of Stephen King John Saul S. A. U. L. John Saul Christopher Pike old school girl most of Stephen King's and rice all that little collection she has of the vampires I have mostly all of John Saul and Stephen King's so that's that's the bulk of it but I have a little off you know random books I have the help I have you know girl with the dragon tattoo stuff like that so I'm like okay let me see what's on my candle so I decided to go ahead and read a book I've been wanting to read by Terry McMillan I really had one ahead and read and I read it over a week yeah so I'm okay I'm gonna make my goal I can do 130 books girl a feasible and reasonable goal for me for reading is would be about five books she's responding to five books a month that's why I'm gonna that's what I'm going to do fine I was supposed to have done a volunteer day with a organization called Dress for Success and what they do is they help either lower income not necessarily lower income that people that don't necessarily have the skill set women not people just women with a job interview styling interviews questions you know do a mock interviews helping them with their attire stuff like that and so I I was excited to do it you guys so I looked at the hours and it's like nine to two thirty I can't do that first of all I I don't even have the physical capacity anymore to volunteer all day I used to volunteer for a long time but I when I volunteer I like to do it in hours hour three to four hours I can't do that's a work day I mean I had 30 see off but I can't do that and also what I was gonna say I had to pick up JB about three o'clock in this place is a downtown Phoenix so perhaps one day when my husband is off I will do it but then I would but I don't think I could do a full day I will ask them cuz I don't know what it what all it entails okay I don't know if I'm gonna be you know lugging dresses around so I will probably more than likely will want to do a little bit more research on the organization which I probably should have done before instead of just flying by the mail and signing up for it so I'm gonna take my time to look it up do do some more research contact them possibly go over there shadow someone cuz they have different areas where you can actually volunteer makeup personal shopper which is what I was going to do which we which you could help someone with their attire cuz I think I'm a you know right now I look crazy but when I go to work oh baby I snatch it together yes head turns they're like where you going I'm going I'm going into the office I'm not one of the one of the best people dressed in my office cuz everyone else is looking like they're gonna go fix some cornflakes girl I don't know so anyway that was canceled I do have a doctor's appointment tomorrow that's okay y'all my what am I trying to say my menu holiday menu is going to be slightly changing I want some dressing yes I want some dressing so I'm gonna be adding dressing to the menu but I don't know about Italian wedding cake because this is the thing y'all saw that butter pecan cake I made it look good didn't it but I didn't like it I didn't like it I know where I messed up at and I know how to correct it oh let's talk about this her real quick girl and this is the only place I could do this so yes the hair is considerably shorter you guys the reason why I was so butt-hurt about it is that I was only a few inches away from waist length and that has been my gold and those you who don't know I shaved my head in order to go natural so I've had short hair I know what my hair looks like I knew I know what a TWA looks like so I worked I have worked very hard to get to where the length I was at I know yeah I know it could grow back but this has been eight years of work to get to I was two inches parts past bra length actually Nezzie did a video recently I was almost her length almost yeah almost her length and her is very long her hair is all her hair is almost waist length so yeah so yeah I was perturbed a little bit so the stylist Ms. Urlat said that she thinks that my hair can get back to its original length by May and then I think that I can get back to birth I could possibly get to waist length by the end of next year if not the beginning of the year following but I know the overall go I've always said to see you guys to have healthy hair and my hair was not at its healthiest I mean my hair was splitting up the ends were horrible and it was starting to split I am really bad about trimming my ends and I know there's some of you who say oh I only trim my hair you know it wants a once a year or two to two times you supposed to be trimming your hair every quarter with my hair especially I know this for myself and I just I got lazy I just didn't do it I mean this has this is honestly I'm gonna clock my own teeth this is my second time this happened and the second time she's had to let me let me back up I didn't do what I did before this is the second time where I've neglected my ends the first time she cut my hair and she doesn't let me go ahead and get rid of these ends and it was it was looking really good she's like she told me then this was two and a half years ago and she told me then you need to keep your ends trimmed do it every three or four months I'm like yeah I gotta go deep condition so this time I tried to do it myself didn't do a good job clearly and then she had to correct it with me losing three and a half inches in certain areas so yeah I mean it's hair it'll grow back but when you've been working as long as I have to get to a certain length and have this type of setback it is what it is it's still very healthy it feels fabulous washed it's gonna be a breeze so cuz I don't have those ends holding me up girl holding me back so hey you guys it is Friday it's Friday yeah I'm not in the mood I think that I'm still a little boned out about my hair I know y'all gonna be like girl get over it miss earlet she wrote me cuz I sent to the video she's like your hair is not short it is shorter but you can't tell me looking at it now um and yes I know it's just hair but one thing that I I wanted to mention cuz one person commented on that video you know you should let her do what she wants you know it's just hair girl now that's what makes miss earlet such a great stylist is because she's one of the few stylists who are actually I shouldn't say they there are some stylists that actually do listen to the client y'all it's okay anyway it's Friday I went staples because y'all I didn't let we didn't take pictures with Santa Claus this year I don't know I just think I think after five and nobody gets a little creepy y'all after five and they get a little creepy and he wasn't saying anything about it we're like whatever child so you know as a baby one of two-year-olds it's cute but now it's like no but what I did do is I printed out a letter from Santa so we're going to bake cookies the night before and of course my chubby ass is gonna get up in the middle of the night and I may do it that night and eat one take a bite out of one leave some crumbs on it and leave the note next to the Christmas tree who's gets me y'all I'm slobbering and sugar thinking about the damn cookies girl mercy so y'all I don't know my mood has been off it's more than just that hair I just my mood has been off and I need to slow down and relax around this time of the year like I said I get anxiety so I'm okay I will be okay just I have a lot going on so right now after this I have a stop at the bank go to the credit union then go get JB his dang on raising Kang cuz I promised him that and then go pick him up I have to do that all of that within 40 minutes yeah so let's just go ahead and keep it pushing one thing I do want to give y'all heads up those of you who watch all my videos thank you first of all um I think 2019 next year will be my last active year as a youtuber meaning consistently uploading um I don't know where I'm going with this but I'm doing a lot you know I have a lot of different videos that come out and I upload quite a bit I upload at this point between three to four times a day I mean a week a day I upload three to four times a week and there are certain things I want to do in my life I'm gonna get my health in order because girl I was at the doctor's office earlier this week and yeah I need to lose some weight you guys get my health in a health in order get my being my down to a health I'm not fat by any means but unfortunately due to things that run in my family I'm more predisposed to cancer high blood pressure which I'm on medication for that now and I'm not even 40 years old so I want to be able to get my health in order get my life in order get my goals in order get back on my career I'm always on my goal you know goal thing but really start thinking about the hell is that start thinking about you know where I want to go as far as my career some things are changing around in my organization so yeah I want to focus on that the word of the day is more dent so yeah I have an application where I download a word of the day girl that's a that's a nasty sounding word you know what I'm saying y'all so I'm literally up I get up early anyway but as soon as I get up I find myself doing something has to do with YouTube either I'm responding to comments replying because I try to be as active as possible or I'm like editing a video I'm getting burnt out so yeah I'm pretty sure next year would be my first full active year as a YouTube you break doesn't mean that I won't be making content I just won't be consistent it will be like once a month or once every other month at this point I was talking to another youtuber I'm not gonna name drop her and she has a lot more subscribers than I do but she has a quarter of the number of videos I have 800 plus videos and my subscriber I just feel like I'm putting in so much work for 17 that I love all of y'all but I just feel like my channel hasn't grown the way it should have and I'm tired too I'm burnt out so yeah I'm gonna slow my role and focus on some other stuff here we go sheet pan meal this is just what I had in the fridge you guys I have some yams in there but I think this is enough this child's getting in my nerves hey I sprinkled some parsley on top some onions chopped up garlic tons of different seasonings pop it in the oven at 365 for 40 to 45 minutes and it shall be done you could serve this with some rice or as is I'm gonna make some spinach so I'm gonna lay the chicken thighs on a bed of spinach and then have these on the side real quick two things about some youtubers good news that I just I saw just today and I think she's subscribed to me gold now she's a sister and I think she did she I know she's in the south is Alabama or Mississippi I can't remember where but she posted a video either late last night or really this morning that she is cancer-free y'all hey man praise God the sister have been battling cancer went through treatment and I just love her spirit I love gold mouth I know a couple of y'all to subscribe to her and congratulations to Buzzfeed for having her little baby girl she posted a picture that baby all I saw was hair I'm like look at all this hair it's time to clean clean with Mariah Mariah anyone knows you know I'm a huge Mariah Carey thing you cannot go wrong this is my washing go looking let's turn around that's no I'm crazy inside inside that is sleeping it is Saturday you can't choke on cam it's Saturday we doing JB what are we gonna do we're gonna go to the tram part this is a thing because they can't hear me because we're in Phoenix it gets dark here early like it starts to get dark around 5 30 I don't know though it this the this time of the season is really weird because the time doesn't change I'm talking hold on 5 5 30 you would think it's 7 o'clock the days are I feel like the days are long I don't know what y'all think those of you live here in Phoenix I feel like the days are stretched out and maybe partially or that is because we get up early but to do something after 6 o'clock it feels like it's 10 o'clock at night at that point but I'm not gonna show them that so what we're gonna do I'm gonna show you not we'll go to the train park and it will be Christmas lights what you gotta show me look that's nice so yeah we'll do that and right now I'm making a list my husband's off starting Monday I need to make a list cuz I want to get scary you know how do you know cuz when I came in here I heard some noise and that's when I saw it I was like what in the world is going on what the glass how did he get through the glass he kicked it down that's what woke me up this tree is so pretty let up but how does it fix it boo boo look at JB and one I got him three sets of Christmas what just holiday Santa's note yeah well it's not Christmas he's gonna have how do you know he's gonna get you a note I'll buy your ice cream


Welcome back. Thank you. We got five whole minutes off. This committee is not health and welfare. This committee is finance and we are at this point think we may have some COVID relief money that can be used for broadband for telemedicine and so but it's got to be up and running by the end of December so we're looking for in your experience is there a cluster is there a particular area is there a lack of connection anything that we could hopefully put together a very compressed project or maybe four or five small projects that could be up and running by the end of the year. If our consultants who will be in hopefully by the end of the week first and next week with their recommendations for the use of broadband and CFR money so I'm going to start with Helen Laban and I don't yeah Helen just introduce yourself. I feel like it's old home day because this is my morning but the rest of the committee is not health and welfare so just tell them who you are and the floor is yours. Great thank you and thank you for giving us the chance to talk about this subject in this committee. So I'm Helen Laban. I'm the Vermont Public Policy Director for By State Primary Care Association. I also 10 years ago ran the Evermont Community Broadband Program with ARA funding to do broadband deployment and close the digital divide in rural communities so it really feels like old home day to me because this is what I was talking about 10 years ago. So some things have changed some things stay the same and I have been nominated to be the one who talks about that very specific overlap of telemedicine broadband infrastructure and CRF funding as it affects healthcare systems in Vermont so I'll give that and then turn over to the other folks to talk a little bit more about how telemedicine is working and just in a short answer to your the questions you have posed there's good news and there's bad news that the bad news is that for telemedicine during COVID-19 we are really talking about reaching every residential address in Vermont and as we know from past broadband work that means that there are places popping up all over the state in every town that don't have adequate infrastructure so that's the bad news there. The good news is that there are many very clever people in Vermont who can get access out to those locations so we do think it's possible to do with this funding and we can make that difference. Just quickly on the telemedicine this was something that we were moving towards slowly in Vermont prior to COVID-19 and it became something that we embraced very very quickly overnight across all different provider types all over the state I know for my federally qualified health centers they went in 90% remote visits overnight from virtually none that's eased back some now but it hasn't eased back entirely and nor will it ever as part of COVID-19 response and you know that that's because the direction is still to minimize unnecessary in-person visits we're still redoing our physical spaces to have social distancing so that limits the number of patients we can see at any given time in person. Patient acceptance has changed I mean how many of us are going to agree it's in a crowded waiting room during flu season ever again after this patients just won't so we know we have to deliver telehealth and of course we're always preparing in case there's another spike another wave where we have to shut down to more strict stay-at-home orders and and more severely restrict those patient visits so that means that we do need to be able to get telemedicine out to all residential addresses and often now those residential addresses also have clinicians who are working from home um reaching their patients and I should say I in these remarks I'm speaking specifically about residential obviously facilities larger facilities will have greater broadband needs but I'm looking at the deployment to households and to residences right now um Helen who is just by by state primary care represent we represent the federally qualified health centers uh ppn and uh planned parenthood of northern new england free clinics and a heck although I am speaking here on behalf of the provider coalition that submitted a letter so I'm speaking more broadly okay yeah okay though I I would love to go down the rabbit hole of fqhcs at any time but now I'm speaking more broadly than that all right yeah um so then obviously we have been delivering these remote cares even without broadband to every residence and we have a couple of workarounds available within the health system for that we have audio only codes that are being reimbursed um we also have folks connecting to hot spots but obviously in medical care there's oftentimes that you need to see things you need that visual component and um often doing those visual exams in a public hot spot for reasons you can imagine is not I would see that is highly undesirable exactly so while we do have some bridging options here what we really need is is broadband at the home that that folks can get that that connection um and so when we look at what what counts is people being able to access telemedicine from home telemedicine telehealth can encompass a wide range of things but there are national standards around this so when we look at the speed and the capacity we need what we're looking at is the speed to have a stable audio visual um conference using a platform like zoom which was actually a that's a pre-covid 19 thing that's a standard platform to use for these visits and for the clinician to be able to run their record keeping platform at the same time so they can take notes and fill out the medical record so we know you know what we use to see what's adequate capacity uh it gets a little murky when you look at the national standards so the um FCC does have a standard for what counts as adequate telemedicine capacity that's for one um we reject that as being way much too slow that's not a that's not a popular FCC position right now um there's another group called t-tech the telehealth technology assessment center which is the nationally funded group to assess technology their estimate I would say also airs on the slow side at 8 2 for being adequate for that basic telemedicine access 8 2 yeah we would say that especially during COVID-19 when you have demands on the household use of broadband 25 3 would be the minimum threshold we'd be looking at to build out to residential areas and and we think that that would in fact be adequate and again when I say we I'm speaking for the provider group we did pull everyone on the adequacy of 25 3 um I now I understand that that's a controversial speed in Vermont that does have a economic development goal of 100 symmetrical uh so I I recognize that um but in terms of the very specific question of what we need to get to residences to access telmes and adequately during COVID-19 uh we would say 25 3 is the answer for that and frankly we we needed it yesterday right so we would put a high emphasis on technology neutral get the job done um get us the access that we need to reach our patients okay um and I would just say in addition to this something that I know you know but I I I do want to note that it's not just a question of the broadband infrastructure right people need to be able to afford that connection they need the equipment to connect and they need the basic digital literacy to make those connections so of course um it is a necessary but not sufficient answer to have this broadband deployed to all these households so you know as we discuss it among uh providers we also talk about those other elements of what constitutes true access to broadband and to telemedicine um and that's the the short summary of of telemedicine and broadband infrastructure and and what we need we need 25 3 to every residence um now instantly if you if you could do that but we do feel that this is crucial in the COVID-19 response okay um committee any questions for Helen at this point okay thank you thank you all right Todd Young there you are unmute my you guys hear me yes I um I did submit some um slides but I don't have permissions to to present them um but I don't have permission what's that we now have permission okay let me just faith is all powerful there you go so um let me just bring up so um thank you for for the invite to discuss this topic I'm Todd Young and the network director for telehealth services for university health network um what I thought I do just give you a brief update of of telehealth status at UVM health network and then uh some some of the assessments that we've done with both providers and patients uh with our rollout to kind of really feed into some of the testimony that Helen Helen just shared um hey you know our response to telehealth was very much like what Helen just said um we we went from a small program at all our facilities before COVID but what we ended up doing in March April May is is we have deployed at deployed at every department over 100 departments um mostly in our inventory clinics but with some patient workflows as well um and just about every specialty and every provider type you can imagine anywhere from primary care all the way to to um ophthalmology and we've gone from having about 150 telehealth platform users to about 3000 platform uh users with both providers and staff in that timeframe uh this just a quick peek at looking what our volumes were uh in the beginning of March all the way up to to the end of May and you can see that we're north most north of a thousand every day but then some days you know we're north of 2000 visits in one day with telehealth and we were averaging we were averaging about 60 a week prior to COVID um so pretty dramatic there um so the good news is we are reaching a lot of a lot of patients but the bad news is we're not reaching all our patients and that's why we're here today and one of the things that that we've done post our our rapid rollout as we called it internally is we've we've been working hard around of this assessment of what what is the user experience of telehealth um both our patients and our provider's perspective and um and this is some directory that's gotten and patients are you know having you know patients that don't have connections within or or network within their homes are driving to locations around the community to to get um to get care and this may be driving to a lows this may be driving to one of our facilities that there's broad broadcasting uh guest networks and this is even prevalent in Chittin County, Milton, Essex, other places we literally have supervisors in some of our offices directing patients to go to places where they know that we have network um um but this is a bigger case in central Vermont and you know some of our other um lion areas. Is this going to a hot spot or is this yeah they're literally driving to to places where they know that that there are guest networks and doing the uh the visits within their cars with their portal uh portable devices which is you know very creative but you know not the best best circumstance um especially you know when you think about pediatrics or something where you know a patient is a family member is trying to connect a patient of a child or what have you yeah that you know we have frequent um situations with unstable networks so people not meeting that 25 three um threshold that Helen was describing and you know that affects the quality of care um and then many patients are not you know we get a lot of feedback from the patients that they're not able to afford broadband or mobile data plans to to get care on the provider side a lot of feedback focusing around you know the time the technical assistance um to deal with these types of issues with with patients and then really interferes with their time to be focused on care um and then the really bad side effect is if if we get into a unstable situation with a with a patient um providers will quickly transition to phone whenever they have a technical issue and you know again that's a quality of care issue for for those patients then um you know a lot of our providers and their staff um have had to practice remotely and broadband doesn't just affect our patients and access to that really affects our providers um and where they live and they may even have they have the means um to pay for broadband but they may not have the ability to have it in their homes um due to you know the situation we have a vermont and then a lot of comments for from providers with the frustration um that um that patients um of uh you know low-income Vermonters not having the ability to get uh to get network and therefore we have you know really a um a social economic and inequality issue for for our patients so you know those are you know those are the challenges that have been uh faced up to us and you know to your chairman um coming to your your question you know what what what kind of things can we do by the end of the year um I agree with how in getting as much broadband or connectivity up to the homes but um there are other strategies that also can um can be thought of and and that would be to sponsor some some projects around getting network into community places where or where we could have some private visits that may not be a medical facility it could be at town town municipal offices it could be at libraries it could be you know places where we could put infrastructure out there for private places um to get care uh outs when when when network isn't available so that we don't have patients driving all around towns uh to to find network um that might be one way to spend some money so that's um that's my testimony all right thank you questions committee all right now I can see you thank you uh Sandra Pearson has a question there you go hi hi thanks I I'm just curious if um for you or others do you bill uh a telehealth console just as if you walked into the office or maybe you're not the right one to ask that Todd but I'm curious about that we do um thank god for for some changes in policy in the front end of the covid crisis that um a lot of the the billing inequities were were adjusted um for fee for service type um uh services so we are billing at par um right now um through uh through some of the changes that were made um by by CMS and our private payers and and senator Cummings will know that I I could talk for the next two hours on that particular question it does depend a by provider type um Vermont has parity payment for things that are equivalent in in-person service so it's the equivalent of an in-person service and it's the same payment there are other telehealth codes again to other things that that aren't the equivalent but that's not really what we're talking about here we're talking about equivalent services all I can say is that this has been the subject of uh intense discussion in health and welfare we we made a lot of concessions in the emergency bill that we did the last day that really moved this forward during the emergency but the question is when you know how long will it be after the emergency before people and um telehealth seems to be less iffy than telephone only and should those um calls still be you know paid and at what level should they be paid uh so Jen is here but we well I'm glad you're still under intense discussion my kid had a a consult with her ear doctor by telephone so yeah our phones aren't that special you can't look down their ear it's hard to argue that it's equivalent but it seemed to be billed like an office visit like so I was just curious so that's basically the practice but but you guys in health and welfare are chewing on that looking at it ear aches was always something I would have just loved to have been able to call in especially when you get them once a month Best Buy does offer a home otoscope that you can use connected to your phone to look in your child's ear just if you're in the market for it go and put that out there there you go it's getting the penicillin at midnight I always had great sympathy for people going to the emergency room with an earache in a kid because they cry a lot at midnight okay um um so any questions for Todd young if not we're going on to Devin and Devin is here hello Devin Green Vermont Association of hospitals and health systems um I don't need to add too much more to what Helen and Todd said we fully support it our hospitals have been utilizing telehealth a whole lot more as well as the telephone only um and I would say that we are pursuing the telephone only because of the broadband issue so we want to ensure that folks continue to get care and all of this we realize that there is a disparity um for people who are more rural or who are low income and so we want to ensure that they still get their care but a better more high quality care can be given to folks if everyone had um affordable broadband so we definitely support Helen's proposal of affordable broadband for everyone and in terms of looking for places where it's needed um you know we can try to give you more specific information but certainly the northeast kingdom certainly areas of southern Vermont central Vermont as Todd mentioned um and we're happy to follow you follow up on more specifics but I would just say that all providers whether it's a one shop therapist a one person therapist calling from their home um to our hospitals are really in need of a better broadband to get that high quality telehealth out to folks um and I think the other thing that's important to know is that there are a whole lot of healthcare workers who want to get out of cities right now and move into Vermont and we have um a workforce issue and we could use those healthcare workers but their partners need broadband and um that would be helpful as well the workforce arena okay any questions for Devin all right so Jill is next good afternoon good afternoon thank so I also um only have a few things to add I uh I think Helen and Todd did a great job of outlining the concerns um just to put a little bit of a fine point on it from the home health perspective our patients obviously can't drive around to go to hot spots so the only way we can take care of them is at home and um and we have been doing that so for home health a lot of what we've done is what we are calling blended episodes where we might provide some care to an individual in person because it's really necessary there's no other way to provide lots of types of care but to the extent that there are follow-up visits or check-ins that we can do remotely we're doing those remotely and so that's really how it's worked um for telehealth for home health we were pretty well set up for it in the sense that all of our nurses already have and therapists have their own laptops or or um iPads that's actually different than many physician practices we were already ready for that piece of it um in terms of the reimbursement just to get to Senator Pearson's question um Medicare actually strongly penalizes us for doing those blended episodes unlike most provider types they have not figured out a way to pay us um so that remains a ongoing federal frustration Vermont has done a nice job of uh working it out for us so there's really nothing we can do here in Vermont um about that but wanted the committee to know that um glad my internet is holding up we're at five one here in Middlesex Vermont on a regular basis so would you like would you like 20 I have mentioned uh your that you would probably relish 25-3 25-3 would change our lives the fortnight around here would be unbelievable the irony of this is I'm broadcasting from Charleston Vermont today in up in the M.E.K. and I have 20 three years so wow yeah yeah Jill's up the road from the state house yep three three and a half miles from the state house yeah I think yeah I think that's I think that's all all my comments I don't want to belabor the point I think we've yeah we're all pretty much on the same page okay any questions for Jill okay Laura Pelosi good afternoon thank you I'm here today for the Vermont Health Care Association which represents the long-term care facilities nursing homes residential care homes and assisted living residences and I'm broadcasting from Waterbury Center where I just got an upgrade to seven three so I drop in and out what are you 10 miles from the state house just about so um so you know it's been really important for um long-term care facilities to have access to telehealth services for their residents in this COVID environment just to kind of set the playing field for the committee members the way it typically works is if you're a nursing home resident or you live in a residential care home or an assisted living and you have to have an appointment with your primary care physician or a specialist for the most part you are leaving your long-term care facility and going to that physician or specialist's office um in this world of COVID what we know is that our long-term care facilities are probably the most success susceptible to entry of this virus and anything that we can do to minimize the amount of exposures that our residents have by having to leave the building to obtain medical and health care services is really important so we know that there are facilities out there who do not have good internet access who've tried really hard in this COVID environment to do a lot more telehealth and that's been really challenging um based on the information I have right now it's pretty clear that our nursing home in northfield uh Barton Glover we've got residential care homes in Derby line none of them have very good access to internet at this point in time our nursing facility in Greensboro apparently there's fiber that is available on the main street but it's a relatively expensive connection for them to try to tap into that service and we're talking about providers who rely very heavily on Medicaid 60 to 70 percent of their utilization is is Medicaid we've also heard of some issues in Bennington County and Rutland County as well so we've got 170 long-term care facilities that span the state so any help that you could provide in helping them increase and improve their access would greatly benefit the residents of those facilities okay other questions and the north field facility is within 10 miles of the state capital yes is in the village of northfield uh mail healthcare yeah right right behind the uh norwich football yes yeah yeah yeah i don't i think they merged the village in the town senator a couple years ago yeah okay sorry but it's practically downtown right yes right practically on the university on the university campus yeah any kind of telephone there was no cell service in northfield i think they have limited cell service now one one provider um i've had to drive to the town offices to get the water turned on in a house downtown you just don't it's i think chelsea is a similar dark hall yeah i wouldn't be surprised we have residential care homes and chelsea we didn't hear back from everybody but it would surprise me for them as well but i think it's it's it's an issue of slow and spotty speeds and they drop a lot of telehealth you know um appointments so in the middle of an appointment the service will drop off we're hearing that from a lot of facilities a lot more critical than if you drop off in the middle of a senate hearing so okay any questions for laura at this point julie tesler welcome thank you very much i don't get to speak with this committee very often uh so my name is julie tesler i work for the vermont care partners representing the designated and specialized service agencies in vermont for us telehealth has proved to be very effective it's actually one of the silver linings of covid-19 is that we've learned how effective it is we went from using a hundred units of the service in january to over a seven thousand five hundred in april and we're finding some benefits uh we have less no shows than we used to have because a lot of people we serve have lower incomes and a lot of stresses on them so now they don't have the same barriers with transportation and child care that used to interfere with access so our therapeutic groups actually have a higher attendance than they did pre-covid we are using audio only for some clients um and that's the best we can do for some folks that don't have access but that's not going to be allowable by cms when this disaster period ends so even if it's a interim solution it's not a long-term solution um i think other people i'm sorry we have a question julie i just when when when the emergency ends you will no longer be able to do telephone medicine or you will not get compensated for doing telephone medicine that's what was the we won't be able to receive medicaid or medicare reimbursement for telephone only we will hopefully we will continue to be able to get reimbursement for telehealth um using audio visual it's it's the telephone only which particularly for elders not all of them have the equipment and have been using this but we're also one of the things we're doing during covet is getting people laptops and computers so that we can communicate with them people who haven't used them before had access to them before we've gotten some grant funds and scrounged up some money so that we're getting more of that equipment out there so we can use telehealth audio visual which is superior um then telephone yes it is absolutely it just that's for some people telephones the only ways we actually have staff who are using track phones and they can't because our staff also live in rural areas and don't always have access to broadband so we have this image of them like you know they're working out of their cars now but that's not going to work as the weather gets colder are the people who work for us I'm trying to think as we talk about how building less expensive broadband to people's homes is an economic disincentive for the long term of getting high resolution business quality broadband and there's a tension here and I'm trying to understand the parts I can't address that's above my head I just know the basic would be really helpful for the the work that we do and the people we serve one of the groups in particular are the students that use our therapeutic schools they tend to come from lower income families and have less access and live in rural areas so our ability to provide education to them because they're coming to us for schooling full-time is really being impacted as well so we're hoping that in the future they'll have access so that's all the information I have to add and I do very much appreciate your committee taking this up and Senator McDonald's you've asked a question I can't answer and I leave it to your committee to deliberate you know what are the cost benefits and how you want to make investments thank you okay committee any questions at this point okay for the representatives out there if you could help us I think we already found out in health and welfare there's CFR money out there for you know the purchase of equipment there's even money out there apart from this pandemic or telemedicine and equipment but we're talking maybe poles and wires maybe wireless but and it might be doable in a town like Northfield which has schools and a nursing home and a veteran's home and there are vet there's veterans money those might be more doable if you can you know just if you can any information at this point that helps us get some small achievable in a very few months so we can't string very much wire but maybe up you know a mile up the road if that's all it's going to take and we'll have the hassle about what speed we're going to hold out for and the cost of holding out for it and the future cost of not holding out but yeah okay yeah so but any anything you can do to help us because I think in the next few weeks we're going to have to come up with a proposal if there's going to be one for using the CFR money for broadband so when you're talking to your folks see you know if one of them knows oh yeah you know something hollow road doesn't have anything and we've got three folks up there that could really use telemedicine and if you got a couple kids in between then or in the same house then we're that just gets us a better argument okay thank you I am we'll see you all probably in the morning um I am looking and I don't yes Charles Martin is here we're a few minutes ahead but Charles is from the Chamber of Commerce and right um from the Vermont Chamber and has been asking to talk to us I think he and I have been playing phone and email tag for a while and just wanted to talk to us about some things that are on the Chamber's mind as we work our way through so this was when we could get everybody fit in so Charles the floor is yours thank you Madam Chair Charles Martin from the Vermont Chamber of Commerce um I wanted to take the time to kind of briefly meet with the committee to express what my members are conveying to me and kind of what I've heard from meeting with just about everyone who has an opinion on broadband in the state both public and private since this whole pandemic kicked off the Vermont Chamber has sort of been doing a lot of thinking about the future of Vermont and we believe that the state is well positioned to become a work-from-home capital um certainly in the country um and we essential to realizing this goal right Charlie would you repeat that would you repeat the Vermont will become what a work-from-home capital a work-from-home yes thank you very much um we're already noticing a mic just speaking with realtors um and sort of our own internal knowledge uh we're already noticing people who are looking to or have relocated here uh because obviously the state of Vermont has done a lot better in the midst of the pandemic than a lot of other urban areas so central to achieving that goal is high-speed internet uh most couples moving from an urban area don't want anything to do with a township that doesn't provide them with equitable internet access so that's kind of where we started off when we were looking at this problem I've been following the DPS emergency broadband action plan conversation to an extent and met with the department as well and we definitely applaud long-term thinking in the legislature related to robust internet access that exceeds federal standards and we support you know any effort to ensure public funds are invested in a very lasting way um but that said we're also cognizant of the reality facing unserved workers who cannot tell it to new children who are unable to tell or learn and patients who like you just heard are unable to access providers I would point out to the committee and I think it's important to understand that these tasks are almost always sufficiently covered through access to federally defined broadband um it's worth mentioning because I know that's a really big part of this conversation so kind of on that note we encourage the legislature to view broadband access as it relates to COVID-19 and the pandemic in two separate parts they're sort of an emergency relief portion and that's bringing access to those students who have nothing and those workers who have nothing and those patients who don't have the ability to access the providers as quickly as possible with whatever it takes to get them that basic basic equipment or basic function then there's that second part that the legislature has highlighted and it's kind of internal goals to provide what I've heard called future proof access that will potentially or theoretically be a little lasting and serve for monitors into the future so that'd be kind of the first the first part of the conversation that I've seen muddied a little when I've seen the public or engaged the public on this I don't think there's as much of a understanding that really what's being discussed is an emergency relief proposal and then separate of that there's an economic long-term economic infrastructure investment conversation at end so in the interest as I mentioned earlier of object approaching this conversation with the objective of mindset as I could I met with virtually everyone with a position of influence on the broadband question the state public and private CUDs schools state agencies and of course the private sector I've also been engaging our membership internally in the greater business community in the majority of those engagements people have expressed support for an immediate injection of funding to provide emergency broadband build out now and one of the reasons I kind of emphasize the now and how this ties into long-term economic planning is people are looking for homes in Vermont right now and as everyone on the committee has probably heard someone from the chamber say one or two times we're trying we have been trying to recruit population to the state for a very long time and if our neighbors to the east and west you know have the rural counties in New York or places in New Hampshire have broadband access and town X in Vermont does not very often times it doesn't take too many conversations with realtors to know that that a couple who's looking for a house or an individual looking for a house will go for the town in the state or the county that has the broadband access and I wanted on the kind of 100 over 125 over three conversation I wanted to kind of provide an anecdote of my own situation my brother and his girlfriend lived with us for about three months they moved in from Philadelphia my brother's girlfriend's an architect he's a graphic designer my wife works for a very well known health provider in the state doing web design and I have been more or less running an economic crisis resource center for the last three months from my kitchen table my speeds and I'm not I'm not happy about this but I also just want to point it out in terms of like kind of highlighting the technology necessary to achieve the emergency relief my speeds average six over three so that's what I'm doing at my house right now and we are not having any sort of technical delays I mean there's the occasional loading bar but we are able to all have our lives intact and we're all able to earn a living and access so we need to access remotely with six over three as a speed and that's running four computers four phones and two iPads simultaneously but I really just want to point that out to kind of highlight when we have conversations about 100 over 100 that is and that is a really great goal but it's also sort of what's necessary for world championship online gaming gaming or sort of projecting a hologram in your kitchen at this point zoom for instance and it's when it has its user advisory that you look at before you buy the product it buys is at least speeds of 1.5 over 1.5 netflix advertises a need for speeds at three megabits per second and youtube tells their users that you need between one and 2.5 megabits per second so I really only say that to point out that people can have people can be provided federally defined broadband at 25 over 3 and meet those basic sort of human needs of telehealth telelearn um access um you know and I've I've heard people are getting kind of creative and it's somewhat disturbing in the way that they are becoming creative I mean it's it's heartwarming but upsetting I've spoken to a few principles at this point um in orange county where I grew up and one of those educators expressed that they had used money out of their own school's budget to pay for broadband build out to the entirety of their special education population because they have no resources coming in and no one was actually serving that those households who are also low income household and rural areas in orange county and I I kind of only say that because you know that's great that they were able to do that that's not necessarily the best use of their their school budget um if they probably want to use their budget on other things but when they do serve those those households they don't they not only serve the students they serve the parents who might need to tell a work and they also serve the whole family who now has access to telehealth capabilities so it really is it really does kind of serve all the trifecta of need when you can actually do that additional build out with just a relatively small cash injection that provides service off the pole to the household um so more or less I just wanted to convey that sort of sense of urgency that I'm hearing on a daily basis on this and I apologize if this is redundant because I know the community the committee has already heard a lot of us to begin with but I felt it was necessary to sort of bring that forward on behalf of my members and the people in my orbit and uh I'm happy to answer any questions anyone might have make sure you tell your principal that buying that uh broadband for students out of his budget is probably reimbursable I will COVID I'm assuming the department of ed will be reaching out because I don't think he's alone in yeah okay I've got sander mcdonald just I want to compliment the witness on thought a thoughtful trying to figure things out and and compare the choices and um I don't anyway that's we don't always get that so I want to thank the witness appreciate that senator any other thank you um and if you again it gets difficult but anything because whatever we do with this batch of COVID money has to be up and running by December 31st so if you can find us some place a an industrial park uh startup um you know sharing group anything like that that could use the help let us know um if it's because we're we're really going to be under the gun here trying to get things out so um thank you no I appreciate that and I'd also say I let faith faith a copy of the public comment we provided on the DPS emergency plan and I have a little there's a little more detail okay so I may have gotten that and missed it in my email but if not faith if you can resend it to all of us it's actually online would you like it also sent to you I will leave that up to the committee is it online for today yes it is okay I can find it then um thank you everyone thank you Charles um I think that's it for the day tomorrow we have a much lighter load um we're going to continue the education property tax and miscellaneous tax discussion and um I don't know if we still have Adam Greshan on or not tomorrow you do not we do not that's what I thought um because he left it to Secretary French to explain what the current thinking is on how they're going to fund ed this year so I must say it's interesting usually we're having a fight over three cent raise in the property tax and this year it's like oh is that all that's your two cents worth it yeah it's not 17 cents but we're going to keep working on that and at this point I think and I think I just said something over to faith to have on for Thursday but um maybe we can get him in on Wednesday so it looks like you might get Thursday and Friday off Friday we may be on if that's when we can get the broadband consultants to talk to us we are going to be meeting on Thursday we are going to be meeting on Thursday okay right we are all right so to campion do you have a question I know I was just wondering about the the meeting on Thursday is that the joint meeting that we were going to do last week with um house technology no it's at the discussion of the bills today eight six seventy four s two hundred and s three ten oh okay thank you that's right the little current use bills I knew I told faith to put something on for Thursday so uh we'll try and get this out for those that weren't here at the beginning I have noted that our tiff bill is sitting waiting for third reading so I'm going to ask if I can get that released it completely slipped my mind because I know I presented it on the floor and then I just kind of lose track of things but it never went through third reading why was that you know madam chair we went home oh I I think I presented it like on Thursday wow and we went home so um it's just been sitting there it's mostly clarifications I don't think there's anything particularly controversial on that one so if we could get it it in case any downtown feels vigorous enough or for those that are in the process of a tiff um it will clarify some of the issues that came up in St. Albans so I'm going to try and get that one out anything anybody else would like to take up let me know


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