States will have 90 days after that release to apply. CMS will then review applications, select states that they think would be good participants in the model. There would be, you know, negotiation of an agreement during the next month, and then the first cohort of states would, as I mentioned before, would not get live until January of 2026. It definitely takes CMS time to change their systems when they're looking at different ways of issuing Medicare payments. So next slide. During our discussions with CMMI, we provided some feedback about what we see as Vermont's priorities for future models. And some of those themes won't, you know, won't surprise folks. But we definitely wanted a model that would have support for rural provider stability and sustainability. And like other states across the country, we particularly highlighted challenges with workforce and health care inflation as particular concerns. Increasing predictability of payments is another area that we emphasize in terms of our feedback, ensuring that any model provides the right amount of revenue for sustainability and really emphasizing that Vermont has been a low cost state for Medicare. We focused on support for investments in preventive care and also community care, making sure that payment models and quality measures are aligned across payers as much as possible, and then also allowing Vermont to keep moving forward on our important health care reform and particularly care delivery reform efforts. So some of those include care for people with complex health and social needs, support for primary care, using the blueprint for health, and the comprehensive payment reform programs as examples, and support for community based services. Next slide. So the announcement itself, as I said, September 5th is when CMMI made the announcement. There's a link to the website on the slide. The website's pretty robust. It includes an overview of the model, highlights. What's the purpose of the model? They talk about three primary components to the model and three eligible categories of participants. They envision a model governance structure. A statewide health equity plan is a key component of the model. There are frequently asked questions, fact sheet, a press release, or a high level comparison with other models that CMMI has. And, you know, just to keep referencing ahead, but ahead actually stands for states advancing all payer health equity approaches and development. So clearly there's centrality of health equity in this model. On September 18th, there was a national webinar about 800 folks attended that webinar. So there's a high level of interest across the country in this model and the slides and the recording from that webinar are on the website. And they're also, you know, interacting with individual states, and particularly the provider community and states. So on September 26th, there was a Vermont provider webinar and somewhere around 100 folks attended that webinar. Next slide. So from here on, there's going to be a mix of slides and content that we've developed to try and it's a pretty complicated model. So to try and summarize some of the high level points of the model. And then we're also pulling information directly from material that's on the CMMI website for ahead. So you'll see it noted when the source is the ahead website. But this outlines the application and implementation timeline that they're envisioning. So they're envisioning three cohorts. You know, the first cohort would be the states that would be most prepared to move forward with this model. Again, that NOFO would be released within, you know, something toward the end of 2023. There would be that 90 day period to respond to the NOFO with an application that would take states into early 2024. And then for these, this first cohort of states, a shorter implementation period. So an 18 month implementation period from, say, July 1st of 24 through to January of 26. And then a total of nine performance years for those cohort one states. So this is a longer CMMI is starting to put forth longer models now. I think understanding that it can take some time to make changes of this magnitude. So that would be the first cohort, second cohort, same timeline for the NOFO and response, but a longer pre-implementation period. So not starting until 2027. And then the third cohort would have more time to digest and respond to the NOFO and then have that little bit sort of an in-between pre-implementation period that would again have them starting in 2027. So three different timelines depending on states interests and readiness. Next slide. So here's some key dates. Again, the announcement has been made, the NOFO in late December or late November, early December will have more details than and anticipate a broad stakeholder engagement process. Then, you know, if it's late November, an application should Vermont or any other state choose to apply the application be due somewhere in the neighborhood of late February or early March of 2024. If we decide to move forward, AHS and GMCB staff will work together. We'll continue to provide public presentations. Again, a partner engagement process, public comment and so forth. Then in the spring to summer of 2024, CMMI anticipates negotiating with states that they select some of the points of negotiation might include savings targets. What is, you know, the payment model look like specifically some of the state targets and I'll get to those in a minute that, you know, accountability is that CMMI and CMS are expecting. So that would be spring to summer of 2024. And then again, that pre-implementation period could begin as early as July for those cohort one states 18 month period taking us to January. Then calendar year 2025 would would be, you know, again, the preparation for the implementation of the model. Again, should Vermont move forward with this, you know, we'd be looking for a bridge between our current model with Medicare and what 2026 might look like. And then again, January would be that model launch for the first cohort. Next slide. So this is CMMI's sort of a head model at a glance graphic. So you can see that, you know, they're they're couching this as a flexible framework. They, you know, want to see it implemented in multiple states. The goal, of course, is to improve health outcomes. They list three particular statewide accountability targets. And I'll talk about those in more detail in a moment. And three primary components, which I will also discuss in more detail on cooperative agreement funding, hospital, global budgets and primary care ahead. And then they identify five strategies for achieving the goals of the model. Equity integrated across the model, mental health and substance use disorder treatment integration. CMMI uses the term behavioral health throughout their materials. That's not a term we use in Vermont. An all payer approach, alignment with Medicaid is a key component of the model as well. And then, you know, attempts to accelerate existing state innovation. So this is how they would show the model at a very high level. Next slide. So this is our attempt to summarize that in words. When CMMI talks about their goals for the ahead model, it looks quite a bit like the triple aim for health care improvement. So improving population health, advancing health equity by reducing disparities in health outcomes and curbing health care cost growth.  Again, the three components are hospital, global budgets, primary care ahead and the cooperative agreement funding. And they identify three primary categories of participants. States, again, or portions of states, it could be regions, but states would be the applicants for the model and there are some key accountabilities for states. Hospitals would also be participants. And that includes critical access. Hospitals obviously very important for us here in Vermont. And then primary care practices as well could choose to participate in states that are accepted into the model. And again, federally qualified health centers and rural health clinics are called out specifically. CMMI has made it very clear that a goal is for this model to include participation by safety net providers. They believe that that's very important for advancing health equity. And then five strategies to achieve those goals. Again, outlined here. Next slide.  So hospital, global budgets, the idea is that hospitals that join the model in those states that apply and are accepted would be paid with a global budget, which is a fixed amount of revenue. And they are really CMS is really focusing the global budget on inpatient and outpatient hospital services. And when they talk about the Medicare component of this model, they're really talking about Medicare members who are in traditional Medicare. So they refer to them as Medicare fee for service beneficiaries. So not, you know, when they think about the Medicare side, they're not thinking about Medicare Advantage plans. They would consider Medicare Advantage plans and the folks who are members of those plans to be in the commercial market. So that's hospital, global budgets, primary care ahead. Primary care practices would have the option to participate in a model that includes a per member or per beneficiary per month payment for those Medicare, traditional Medicare members. There would be a quality component and accountability. And they are saying that eventually, maybe as soon as 2027, there could be a track or an option for practices to transition into a payment that's more prospective or capitated type payment. Some of their other models have tracks like that. And so I think they're thinking that they would want to offer a track like that for primary care in this model, eventually. And then the cooperative agreement funding, it's, you know, what they're saying is that for states that participate, they would provide up to $12 million in funding that would support planning and readiness and implementation efforts. And, you know, during that pre-implementation period, but also the initial performance years of the model. So they're saying that a total of $12 million over up to six years. So, you know, not a huge amount of money, but some funding that could be supportive of preparing for a model and the care transformation that be part of the model. Next slide. So I'm going to first dig into what are the statewide accountabilities? And then in turn, I'll talk about primary care ahead, the hospital global budget component, health equity and model governance. So that's sort of where this is going. So again, this is a slide taken directly from CMMI's presentation, but their expectation in this model would be that participating states would be accountable for a number of measurements and targets and goals. And again, if it's the whole state that applies, that it would be statewide. If it's a region, then it would be the region. They would look at who are the residents that are in the whole in the state or region, and these these metrics would be applied to that. So the first is, and, you know, they group these under their goals. So in the improving population health and advancing health equity realm, they have several targets. The first is looking again at those traditional Medicare fee for service residents. They want to see increases in primary care investments. So they they want to look at what, you know, what proportion of health care dollars are being spent on primary care, set a baseline, set a target, see increases in that level of primary care investments. So they want to do that for the Medicare population and then also for the all payer population as well. And then similarly for both Medicare and Medicare fee for service and all payer, they expect the state to establish measures and targets for quality and health equity. So, you know, and and those quality and equity targets or TBD, there will it sounds like there will be some parameters around them, but there also may be ability for the state to select measures that are most meaningful in those areas. And then in terms of curbing health care cost growth, there is an expectation that there will be total costs of care targets for both Medicare fee for service and all payer as well. And that will be broader than your inpatient and outpatient services that are the subject of the hospital global budget. And that sounds familiar to us. We have total cost of care targets in our current model as well. And that's an ongoing concern and priority for CMS and CMI. So those are the statewide accountability. Some, you know, familiarity there from our current model with some of these some new things like the primary care investment and the particular focus on health equity. Next slide. So let's dig into primary care ahead and, you know, what they're, you know, they're putting forth a payment model for participating primary care practices. They are saying that on it from Medicare for those Medicare fee for service members, that there if practices choose to participate, there would be an enhanced per member per month payment for those Medicare beneficiaries that would average about $17 per month. There will be some adjustments to that based on social risk, which I'll get to in a moment, and state performance on some of those state accountabilities. But the floor for these enhanced payments for primary care will be $15 per month and the maximum will be $21 per month. So they as part of their equity strategy, CMS expects to see provider payments adjusted for social risk so that practices that are serving more vulnerable on folks would see potentially higher levels of support. And they also want to see some accountability for quality. So a small amount of those additional payments will be at risk based on the practices quality performance. They talk about some of the elements that the payments could be used for. And that includes infrastructure and also includes staffing. And they give some examples of that, care coordinators, community health workers, mental health and substance use disorder treatment staff, all with a focus on supporting advanced primary care. And this felt pretty encouraging to us because a lot of this is work that we've been doing in Vermont for a number of years through the blueprint for health. So our providers have been doing a lot of this advanced primary care work already. And then another element of primary care ahead and this really speaks to now we're sort of getting into the multi payer aspect of the model, but they really strongly emphasize the importance of Medicare and Medicaid alignment. And certainly they want to seek commercial alignment too. But one of the requirements for practices that participate in this model would be that they would be required to also participate in Medicaid transformation efforts. And one example they give is patient centered medical homes. And again, this felt aligned with what we currently do in the blueprint for health, you know, patient centered medical home recognition for primary care is a key element of the blueprint for health. That's really foundational. So that seemed aligned and interesting based on the work that primary care has done in Vermont and the work of the blueprint. Next slide. So this again, this is CMS slide, CMMI slide, but it shows the sort of the accountabilities for primary care under this model. Again, you know, care transformation requirements, person centered care aligned with existing Medicaid transformation efforts. So they group it into three areas. Health related social needs, mental health and substance use disorder, treatment, integration and care coordination. So under the health related social needs category, they talk about ensuring that folks are screened for health related social needs. That there is work to identify and strengthen relationships with organizations that that address those social drivers of need of health. And then they and they discuss incorporation or embedding of social workers, community health workers or other staff to help coordinate resources for individuals with health related social needs. Again, this sounds pretty aligned with what is happening in the blueprint for health and particularly the blueprint expansion pilot that was approved by the legislature last session. So looks looks like it's really familiar and and related to work that we're already doing. In terms of mental health and substance use disorder, treatment, integration. In that category, the examples they give are reporting on mental health and substance use disorder quality measures. We do some of that now. Our current model statewide has the statewide accountability about half of the measures relate to mental health and substance use disorder. There's a number of measures that really are reflective of coordination of care or screening and and follow up for depression. So we've got a number of measures in our current work that focus on mental health and substance use disorder. They talk about developing warm handoffs to mental health and SUD providers and managing medications for people with complex mental health and SUD conditions. So that's that portion. And then care coordination. There's a focus on on referrals to specialty providers. So they talk about, you know, practices developing work streams to establish those relationships with specialty care, how to formalize some of those referrals, including through through e-consults and other agreements and then fully aligning referral systems across Medicaid and Medicare. We'll need to see a bit more detail on this one to see what they're what they're referencing here. But so those are what they see, you know, here. They want to provide more support to primary care. And then they also want to, you know, help use that support to transform care delivery. Next slide. So that's that's a pretty high level overview of the primary care. The hospital global budgets in the head model, there's several key elements that I wanted to call out. You know, the first is what is it and how generally do they anticipate that it'll be calculated. So the global budget would be prospective would be a predetermined amount. Again, as I mentioned earlier, would be limited at least to start on inpatient and outpatient hospital services. The calculations would be based on historical spend. They did call out that there would be annual updates for changes in population served and for inflation. Sarah will be a director. Kids there will be going into a good deal of detail on the work that we've been doing with a, you know, multifaceted hospital global budget technical advisory group where we really looked at, you know, how what might we want to see in calculations of hospital global budgets that here again, they want payments to be adjusted for social risk and also for quality. They have indicated that there would be a bonus for hospitals that show improvement in health equity. And they also have indicated that in the first two performance years, there will be an additional payment that they're calling a transformation incentive adjustment. And the idea that would be to support investments and enhance care coordination. A third element is that, you know, they as part of the accountability, they would look at making adjustments to budgets based on total cost of care broader than the inpatient and outpatient services. And for that and the next measure, they would look at, you know, those fee for service Medicare members that reside in the hospital service area. So some accountability on total costs there. And then also what they're calling effectiveness and the example that they use for effectiveness of care would be avoidable utilization. What's the level of avoidable utilization that's happening? And then I wanted to directly call out this quote from their materials. What they've said is that participating states with statewide rate setting or hospital, global budget authority and experience in value based care can develop their own hospital, global budget methodology. CMS will provide alignment expectations for state designed methodologies and will need to review and approve those methodologies. So I wanted to highlight that there's a potential option for states that have done work in this space or that have authority to do work in this space to have their have state designed methodologies. So there may be some opportunity for some states to augment or, you know, tailor a bit for that global budget methodology. And again, the work of the hospital, global budget technical advisory group will be very helpful if Vermont decides to apply and go this route. Next slide. So this is CMS's slide on, I mean, they have many slides on hospital, global budget, but this one seemed like a good summary. You know, they talk about an aim as being rebalancing healthcare spending across the system. So shifting utilization from acute care to primary care and community based settings. So I felt like it was important to highlight that.  What might make hospitals want to participate in this model. Again, that initial transformation funding for the first couple of years, you know, we hear a lot in payment reform that financial stability and predictability are really important. And this this model may actually provide a bit more predictability than what we've seen in the current Medicare version of the all payer ACO model, but we'll need to see more details to know if that's the case. Yeah, there's some ability to share in savings. If there's reduced avoidable utilization and other improvements in care delivery, some potential to earn upside dollars. Again, for improving health equity and quality with, you know, with the ability to really focus on population health. And then there are some care delivery Medicare waivers that may be available under this model that could help. And I'll give an example of one that we're familiar with it, which is that requirement that there be a three day hospital stay for Medicare members before they can go to a skilled nursing facility, a waiver of that as a continued possibility in this model. And then they talk about system learning opportunities. So, you know, that's that that's what they will put forth as what they see as potential incentives. Next slide. So I want to spend just the last few minutes that I have talking about health equity. Again, it's obviously central to this model. And CMS has put forth a definition. And again, I felt it was important to quote it directly. So they define health equity as the attainment of the highest level of health for all people. And by the way, the emphasis is theirs here, where everyone has a fair and just opportunity to attain their optimal health, regardless of race, ethnicity, disability, sexual orientation, gender identity, socio-economic status, geography, preferred language, or other factors that affect access to care and health outcomes. Next slide. So this is their slide that outlines what they see as the health equity strategy. So it would include a number of elements. The first, as I already had mentioned, as part of that statewide accountability, there would be targets for equity and quality measures. And in addition, or as part of it, perhaps, there will be a requirement that there be a state health equity plan. So that's the first element that they call out. The second is enhancing partnerships between states, providers of the community to meet model goals. Third, I had mentioned earlier that safety net provider participation is a priority for CMS. And so they want to see that recruitment and participation from critical access hospitals, FQHCs, rural health clinics and so forth to ensure that vulnerable populations are included in the model. It also mentioned social risk adjustments. So that would be present in both the primary care and the hospital global budget components of the model. And then I had also mentioned health-related social needs screening by hospitals and primary care providers to ensure that we're identifying needs and connecting folks to community resources. So those are the elements of a health equity strategy that they call out here. And then next slide. So one key element of the model is that they have indicated that participating states will have a multi-sector, what they call a model, governance structure, with a formal role, an advisory, you know, in some cases, I think in terms of developing that statewide health equity plan, so significant formal role in the work. And they note that states can build on preexisting work groups or boards. And then they do outline what they see as what individuals should be on that governance structure. So they specifically call out patients or individuals and or advocacy organizations, community-based organizations, payers, and that would include commercial payers as well as the public payers, provider organizations, local tribal communities, state Medicaid agencies and departments of health. So they really lay out required participation or representation and then list a couple of optional opportunities as well. And then the governance structure role would be to develop the statewide health equity plan and provide input on those quality and equity targets, review and support hospital health equity plans and provide input on how that cooperative agreement funding would be used. And then some optional roles as well around the hospital global budget methodologies and other activities for the statewide targets. So that's a key component of the model. Next slide. So I'll close just with, you know, there's some questions that we'll want to address between now and next June or July. The first is what do we do for calendar year 2025? Can we and will we extend the current model to avoid going back to fee for service? Will we apply for the ahead model? Will, say we do apply, would we wanna propose our own state-designed hospital global budget methodology? Say we apply and we're accepted, would we be able to come to agreement with CMS on an agreement? So that's a question that time would tell and then what would be the composition of that model governance structure group? So I will stop there and apologize for taking until 1.55. I am fortunate to have a hard stop if from 2 o'clock. Thank you very much, Ms. Jones for that update. We'll go straight to Director Kinsler. I think it's topical because we have been working on developing our own state global budget methodology to propose to CMS as Director Jones mentioned. So, Sarah, I'll turn to you. Thank you so much, Chair Foster and thank you to Pat for joining me today to share this content because I do think it is past presentation on the AHEAD model and this update on the activities of the global budget technical advisory group are very related, as you say. So for Director, this is Sarah Kinsler, Director of Health Systems Policy for the Green Mountain Care Board. As Pat mentioned, Act 157, well, as Pat mentioned, we've used the slide before. She was really focused on our green box here on the subsequent federal state agreement. And I'll give you an update now on our work to develop value-based payment models, specifically a hospital global payment method. Act 167 really predates our engagement with CMMI around a potential multi-state model, which became the AHEAD model. But I think Act 167 was very kind of prescient in predicting that this would be a place where CMMI would want to go and where we, as a state, would also have interest in going. So that's kind of excellent alignment there. And it has allowed us to really be ahead of the game, I think, ooh, terrible pun on intentional my apologies. It's allowed us to act very quickly and in advance to think about how a state-developed hospital global payment methodology could interact with this new federal program that we're still learning more about with more information to be revealed as we get the now phone. So I have a couple of slides in here that are a little bit of recap and content that you've seen some version of before, but I want to include it every time we talk about this since it's complex work and so much is coming coming at our board members and members of the public who attend our meetings. So as a reminder, we convened the hospital global budget technical advisory group in January of this past year. It is co-chaired by board member Robin Lange and interim director of health reform for the agency CMMI services, Pat Jones. So Robin and Pat lead our group and the charge is to really make recommendations for conceptual and technical, for a conceptual and technical specification for a multi-payer hospital global budget or global payment program. As we learned more about the AHEAD model, it became clear that the charge included to do that by the time CMMI introduces a future multi-state model. We know that this will help us in a few ways first by giving us something against which to assess the CMS methodology, the CMS developed methodology. And now that we know that there's an option for states to prepare and propose their own methodology within federal guidelines, it means that we've already started that important work. And so that will allow us to kind of assess where we're at when more about the specifics of the methodology is released. So again, we anticipate federal limits and guardrails for any state developed model. So I do want to say just say out loud, and I think Pat said this as well. We anticipate that at least for potential Medicare participation in any future global payment program or global budget model, that we don't have entirely free reign. But we're thinking about how to kind of tailor to what Vermont, we think Vermont needs, what we think Vermont providers need, what we think will support to help our population. And by the end of this year, we hope to have a fairly well-developed strong model specific to Medicare, but identifying those places where we would expect Medicaid and commercial to potentially diverge or to meet their own additional work. We meet about every three weeks for two hours. And we've asked a lot of these group members. So I want to extend my thanks to any tag members who are on the call for the time and effort that they put into providing us with their feedback and perspectives. And all the materials are posted publicly and that's linked in these slides. I think in a few places, you can find that on our website. So as we have gone through the tag process, we've been working fairly methodically through a set of topics. And I'm going to bucket those. And as you see, we're checking a lot of them off now. I am bucketing those into three areas. The first is around scope. What's the scope of the model gonna be? How broad are we gonna get in terms of services and in terms of population payers? What kind of payer and hospital involvement might we get? The second is the mechanics of actually calculating the methodology, which looks small on the slide, but is in fact, I would say a huge bulk of that work. There's so many technical details and issues to work out. And then finally an area that we're still exploring now and on which we'll spend most of the rest of the year thinking about strategies to support transformation, how the budget is administered and overseen and how we monitor and evaluate any future global payment methodology appropriately to ensure that it's producing good outcomes for the marketers that we have our eye on quality and access and all the equipment, equity and outcomes, all the things that we know that we as a state care about. So I'll review each of those in kind of summary. Some of them you've heard about because we had worked through these issues before previous presentations to the board, but some of them are new, so we'll give you an update, but I'll keep it brief where there's a recap since I know we have other business to discuss today. So in terms of the scope of the hospital global budget for the included populations, I think the upshot here is we, at least in our modeling and our conceptual work, we are aiming to think about this as broadly and inclusively as possible in terms of the population. So we're thinking about hospitals, global budgets on a facility basis. And so we want to include as much of the population served by each hospital as we can. So this goes into in-state, out-of-state residents, and I'm not gonna focus on that today, but in summary, we're trying to cast a wide net and ensure wherever it's appropriate that there is cross-payer alignment. Secondly, included services. You heard from Pat that in CMS's global budget methodology, they plan to limit their work to hospital inpatient and outpatient services, at least initially. There was very strong interest among our technical advisory group members in including additional services recognizing that our current all-payer model does look more broadly in terms of services, services included in the model, to include things like professional services. And as we continue to look into the feasibility of doing that, we ran into some challenges related to data availability and kind of operational challenges. So where we landed in our straw model has been that while we would start with hospital inpatient and outpatient, there's certainly enough methodological challenges to work out there to give us ample to work on. We would speak to phase in professional services at a later date to give ourselves a bit more time to build the data infrastructure that we think is necessary to do that accurately. And then this is, here is an example of newly discussed information that was discussed at our technical advisory group meeting just yesterday. We had kind of a first conversation around what should the terms of hospital participation be? And I should say, you know, our technical advisory group represents hospitals that represent payers, there are advocates, union representatives, health equity experts. So we've got a pretty broad array of folks participating. And unsurprisingly, we didn't achieve immediate consensus here, but we did receive really informative feedback and perspectives from across that spectrum of participants. So, you know, this is an area where we'll be having some subsequent discussions with stakeholders and seek to engage our partners more on this before we, you know, have any final recommendations. So moving on to calculating global budget sentiments, this is largely a recap. I wanna note, we're looking at using, again, a facility-based approach that we're thinking about facilities net revenue for the services that are included in the budget, looking at a historical probably two to three-year average. And as we look at the baseline budget, we are thinking about potential one-time adjustments to the baseline to accommodate factors like hospital financial condition, including hospital operating margins. So potentially considering, you know, ensuring that we're not baking in losses to a future global budget, but again, not a final recommendation. The baseline budgets would also need to include prospective adjustments for things like inflation trends, membership and demographic changes, policy changes like changes in Medicare policy, as well as planned service line changes. So if a hospital were to plan to open a new service line to meet any needs or to reduce or eliminate a service line because it's not reflective of community needs. Then as we, you know, start moving through the years of our global budget methodology and we'll kind of, I'll show you a drawing for that next. We think about how to trend forward from that baseline. So there would be annual prospective adjustments, the same prospective adjustments that I just listed, but there would also be additional annual or ad hoc adjustments. And those could include things like market shifts, special adjustments for tertiary or quaternary service volume, special critical access hospital adjustments, which is an issue to be discussed at a future date, as well as performance adjustments. So as Pat said, adjustments related to total cost of care is likely going to be something required by MMI adjustments for population health achievement, financial health efficiency, service access review, all of these are on the table and we're kind of working to think through how they could be defined and operationalized and what the right balance of incentives is. We're also, you know, when we talk about considering adjustments to mitigate provider financial risk, we want to make sure that that's in fairly extreme circumstances and think about how to make sure that, you know, the incentives toward providing efficient care and keeping your population healthy remain in the global budget without being so strong that, you know, they provide an incentive to limit access because that's certainly something that we would not want at all and something that we would want to really actively monitor for. So here's the kind of visual depiction of the strong model and it's really just showing the steps of working through a global budget. So you start with determining baseline payments. You figure out how to perfectively adjust. You make your year one payment and then, you know, you're thinking about how to update and trend forward from there. I want to highlight that this strong model is specific to Medicare fee for service but again, as we're developing a strong model, we're identifying places where Medicaid and commercial may need to differ and we choose to differ. And then finally, we are just barely starting our conversations about provider transformation, budget administration and calculation and evaluation and monitoring. So we had a very first conversation about transformation at our tag meeting yesterday. And again, got great feedback, did not reach conclusions yet but that is, you know, not surprising for our group and it'll be something that we continue to discuss and work through together. We'll have a lot more conversation about that as we go along. And then in our next couple of meetings, we'll be talking about global budget administration. So who actually does the calculating how's the budget overseen? And then I'm monitoring an evaluation framework as well and that'll be our work kind of from now through December. So again, as we work, we'll, you know, continue to build on that Medicare fee for service draw model, continue to think about how to adapt that, especially for commercial, which we'll probably start to take on in early 2024. We're also anticipating providing hospitals with additional modeling resources so that they can really play out what does this look like for them, for their organization. And in the meantime, you've already heard about the key issues that we're tackling. We're also engaging with different constituencies, different groups, different partners, kind of outside of tag meetings to get some one-on-one feedback. And that includes meeting with hospitals, meeting with payers, meeting with other partners. We're hoping to bring together some critical access hospitals to get some critical access hospitals specific feedback on what policy adjustments or other needs COS might have to successfully participate in this model. And then finally, I just wanted to list for you kind of what we've got on the docket or what we're hoping to address between now and early 2024. So we'll be meeting with us toward the end of this month and hope to continue to engage with them as well specifically with critical access hospitals. And we are in the process of meeting one-on-one with some payers to understand where model might need to differ for commercial payers and how data intends to align with their diverge from any future Medicare model. That's all I have for you today. Thank you very much, Director Kinsler. Why don't we take a quick five-minute break before we turn it over to Ms. Melamed and then we'll turn to her when we come back because we'll come back up to 16. Okay, we will reconvene and we'll turn to Ms. Melamed who's our Associate Director of Health Care Policy and she's been leading a lot of the Act 167 community engagement work and I'll turn it to you, Marissa. Thank you, Chair Foster. Good afternoon to the board, members of the public. Can you see my slides? Yes, okay. Okay, so hi, good afternoon again. Sorry, I was having a technical difficulty there but I think it's all good now. My name is Marissa Melamed. I'm the Associate Director of Health Systems Policy with the Green Mountain Care Board and I'm serving as the Project Director for the Act 167 community engagement to support hospital transformation work. I was meant to be joined by Dr. Bruce Hamery today, Partner and Chief Medical Officer of Oliver Wyman Healthcare and Life Sciences who is the principal contractor helping to lead the community engagement process but he unfortunately had to cancel it last minute due to illness. So it will just be me today giving you a project management update and we will have Bruce back as soon as we can so you can hear from him on the engagement plan approach and updates so far. So don't worry, we'll have Bruce back but I think I have some helpful updates for you today. So you all seen this slide today already a couple of times. Act 167 includes these four work streams. The first two were addressed by Pat and Sarah. The blue one there around the evolving Green Mountain Care Board regulatory process. I'm sure you'll hear from healthcare finance team another day about so we're gonna skip that one and talk about the community engagement to support hospital transformation work which is being led by the Green Mountain Care Board in collaboration with the Agency of Human Services. Just a really quick background on this work which has been building for quite a few years now both in the work of Green Mountain Care Board and through the legislature. You can really date this work specifically back to 2019 and 2020 with the Rural Health Services Task Force requirement to provide sustainability plans in the wake of the bankruptcy of Springfield Hospital and then in 2021, 2022 the hospital sustainability report and requirements to the hospitals provide sustainability plans and then in 2022 with the passage of Act 167 which required these work streams being discussed today. So what I'm here to do today is roll out for you the public engagement process that's required by Act 167. And this is to support the development of options for transforming Vermont's healthcare system to improve access, affordability and sustainability. The legislature identified and mandated the community engagement process as a crucial step in matching potential options for our Vermont Hospital and health systems with the unique needs of Vermont communities and regions. So what is the community engagement process? Who should participate? When is it and what are the expected outcomes? So the what is community listing sessions and data sharing to gather input on the current state of the hospital and healthcare delivery system on met needs and opportunities. The, oops, sorry about that. These meetings are divided into two categories. Community meetings are for anyone impacted by the healthcare system. So this is a broad net and provider meetings are for people who provide or help support healthcare services. And this includes physicians, nurses, social workers, EMTs, pharmacists, healthcare support staff, et cetera. The process will take place in fall of 2023. So this week is when we'll be launching the more public portion. We've been working for several months on the plan and we're ready to launch the public process, which I'm gonna explain more to you in the next couple of slides. And then in spring of 2024, there is a second phase. And the outcomes or the outputs from these phases, the first one is a synthesis of input, the input that's gathered from the community and the provider meetings and any interviews and focus groups and hospital meetings. And phase two, the output is options for state entities, communities and health systems. And this will be in two rounds of statewide meetings. So the first in the fall will be to gather the input and then the Oliver Wyman team will come back to the communities to talk through the options and recommendations. So here's a review of our progress so far that are recapped. So as directed by the legislature, the Green Mountain Care Board has retained an expert to support the data informed, patient-focused, community-inclusive engagement process. The expert that we have retained is Oliver Wyman Health and Life Sciences Practice and they began in late summer by reviewing data and preparing to facilitate the listening sessions. The listening sessions will gather local input to inform options for state entities, communities and health systems to implement that ensure Vermonters have sustained access to affordable care. And they will be working directly with community members, businesses, hospitals, providers and healthcare organizations to ensure a wide range of voices are represented in these discussions. We also have help from a current data analytics contractor, Mathematica Policy Research and they will provide data analytics support, particularly for the phase two around impact and sort of forward-looking analyses of these options and recommendations. So here's an overview of the phase one public listening session. That's what we're gonna start now. There are, we're about to launch the schedule of 32 virtual public listening sessions. These will be hosted and facilitated by the Oliver Wyman team on the Zoom meeting platform. They are scheduled regionally by hospital service area. There will be 18 community-focused meetings. So that's one per hospital service area and then there are four scheduled as a statewide catch-all. There are 14 provider-focused meetings. So that's one per hospital service area. The meeting times are varied from four to 6 p.m., 6.30 to 8.30 p.m. and 9.30 to 11.30 a.m. to try to give people options. Again, the meetings are focused around community at large versus provider and regionally. So we are trying to capture regional insights. However, there is, you know, people can choose which meeting is appropriate for them based on their location. What perspective they bring or even just the time that works for you. And this schedule runs from October 25th, so two weeks from today through November 16th. So it is pretty tight and sort of a full statewide effort over the next month or so. And then the meetings in this phase are what will inform the phase two meetings, which is the development and vetting of options with communities, which we do not have a schedule for yet. Those will begin in the spring after a pause for synthesizing insights and analytics and then the team will come back this time in person in some cases to talk through the findings and recommendations developed through the first round. So this is how the board and the public at large can provide input. This is kind of the specific ask for all of you on the meeting today. So for board members, in phase one, we will share the schedule with you and we can talk about having you attend as listeners across these meetings so you can hear what's being said from people who attend. In phase two, we would ask for board member feedback on priorities and options for transformation, based on your areas of expertise and where you from your position as a board member for the public and impacted groups to provide input. In phase one, all of the Wyman team will review local, current and future state data to give people context in grounding and what is known and sort of what the healthcare system is facing. And then they will be asking for members of the public to share their experiences, brainstorm, prioritize local needs, really get that local and community input. And then in phase two, when the team comes back, it would be to provide feedback on priorities and options for transformation based on what all of the Wyman brings back to the table. So finally, at least for my part, we are asking folks to check the Bean Mountain Care Board website soon for the full meeting schedule and to register for meetings. I'm sure when we get that posted, which we are working out pretty much as we speak, it will be available on the hospital sustainability page and I'm sure the next public meeting of the board, we can have Susan or the chair announce that that's public so that people can go to the website. We are waiting to launch it so we can have the ability for people to sign up directly for the meetings that they would like to attend and receive invites on your calendar and make it easy as possible for people to schedule and get information. Materials for the meetings will also be posted. And I apologize, the writing on here is small, but I think this is helpful. There's a few questions that people might have. I think I've gone over some of them, but if you're not sure which region to join, as I said, it's organized around Vermont's 14 hospitals. You're invited to join the discussion for any region that you feel connected to. It could be where you live, where you work, where you receive healthcare services. These can be different in different cases, but we are modeling the meetings around regions so we can understand who each hospital serves and what their community needs are. What's a provider meeting versus a community meeting? I think I probably covered this already, but again, community meetings are for Vermonters about their lived experiences with the healthcare system. And the provider meetings are tailored specifically for those who provide or help support healthcare services. And you can come to either meeting as it applies for you or if you want to listen. And again, if you can't attend a meeting in your region, you should go to a meeting that you can go to. There are also other ways to provide feedback, as Susan always starts the meeting. We all have specific public comment that can be directed toward this project and will be shared with the Oliver Wyman team and included in their analysis. So we encourage written feedback, video, audio recorded feedback we want to hear from you. So I'm gonna, like I said, Dr. Hamery could not be here today, whoops, hold on. There it is, could not be here today. And the Oliver Wyman team actually has an offsite today. So we'll have to bring them back, but we wanted to make sure to at least give you this update. Dr. Bruce Hamery is the principal in this project. He has an extensive and long career leading large healthcare systems through transformation as well as experience with rural hospital systems. He also probably sounds familiar to many of you as he led the state's wait times workforce or wait times, healthcare services wait times group. Can't remember the formal name. I think that's familiar to most people on this call. And so he's back to, with great enthusiasm to help us with this project. He is joined by Elizabeth Sutherland who has a background in systems engineering and management and has led several health equity initiatives with states. And she is the health equity expert on this project, which is a priority for this effort. And then they are joined by two project managers and subject matter experts, Chedera Chiquake and Sam Winter, and they both bring with them quite a bit of background on the payer and provider space in healthcare and have been helping us to manage the project both on the sort of logistical community outreach side and the data review and analytics side. So we're super excited about this team. We want people to be familiar with them. You'll hear from them. They will be facilitating the meetings and synthesizing the insights. And many people on this call have probably already talked with them and heard from them already because we have been reaching out to impacted groups, community leaders, hospitals, provider associations as we've been developing our outreach plan to date. So I also want to thank all of the people that we've met with so far, legislators as well to help us formulate the plan that we're now ready or getting ready to publicly launch. Here is the contact information. So as I said, I'm the project director with the Green Mountain Care Board. I work very closely with our health policy analyst, Hillary Watson, who is helping me wrangle all these meetings and data as well. And so please do not hesitate to reach out to either of us or both of us with any questions about this work. The Oliver Wyman team emails are also on here as well so people can reach out to them directly and just be familiar with who they are and their names in case you receive outreach from them. And here's the link to our website again where you'll find the schedule once it's posted. I think that brings me to the end.  And thank you. Thank you very much, Marissa. Open up to the board for any comments or questions board members may have. I have one comment which is for anybody that's on. I really encourage participation in meeting with the Oliver Wyman team as much as possible. We want as many different constituents in our healthcare system and patients, businesses, everybody as much as we can so that we get this as informed as possible. I think this is some of the most important work that's being done in healthcare in Vermont. So I really encourage as much participation as we can get. I'll turn to the healthcare advocate for any comments they may have. Eric, I see you but I don't hear you. Nope. All right, Eric does not have a comment today. If you want to email us anything, Eric, you can. And with that, I'll open it up to public comment. Mr. Davis. Thank you, Mr. Chairman. There's got several comments. I'd like to try and make them as short as possible. I think that on the question of the public meetings, I think it makes a lot of sense for meetings with providers, but in point of fact, people always do this, they've always done it, always sounds great. Let's ask the people what they want. I think that will get you nowhere. And the reason is that the public generally has no idea how to make real choices about what kind of medical care is available and where it's available. They just don't have, they don't have any idea. And you can, so it's just, it's an exercise and I just think it's not going to work. Look to talking to providers on the other hand, has would be valuable, irrespective of what kind of stuff they came up with, at least in my view. Secondly, looking at this whole project, and as you know, I've made some made comments about your process over the last year or so. I think that if looking at it from 30,000 feet or whatever, I think that what you really have two jobs here, and I think two jobs really, and it really doesn't involve the feds, it really involves the way that you deal with the system. The first question is, can you save the university, the academic medical center? That may be gone. I mean, people that really understand the system from inside already believe that the academic medical center is gonna have to be sold to somebody. They just hope to somebody good like Kaiser instead of somebody terrible like the OAC. Now, I know people will disagree with that and we'll just see what happens. But the reality is that UVMMC simply doesn't have enough money and hasn't had enough money since 2018.  The second huge job is to rationalize the small hospital network. Vermont has very low costs compared to the rest of the country. But the reason they have low costs is because of the UVM numbers. The UVM, and this data is including with Dr. Hamry, read his Dr. Hamry's analysis of this system has been available to you for two years. I understand that the saying anything is like the third rail of some kind of third rail of politics. But the reality is that the reason that your costs are low in the state is because of what's happening at the UVM health network and not because of the others. The smaller hospitals have costs compared to UVM on a population basis, which is the only one that matters. They have costs that are a third to a half higher than UVM. Secondly, if you look at the quality, if you look at the PQI data, at the PAU data, at the data that is put out by all your consultants, including Hamry, then the reality is that the idea that we need 16 fulls, I mean, 14, six full service hospitals in Vermont just doesn't make any sense at all. And it just doesn't. And so what I'm hoping is that the thing that you're doing with Hamry and the sustainability thing, the original idea for sustainability came out of the board itself. It came out of Jessica Homes. But the nobody had, I've never seen anybody really, that looks to me like they're willing to grapple with the reality. Somebody thinks that we need, we used to have, is Bob, or when I started, when I regulated, when I had your job as the chairman, it was a lot easier, I have to tell you, is that we had 16 hospitals. We used to have hospitals in Rockingham and two hospitals in St. Albans, Hospital in Barry City, Hospital in Winooski, those are all gone. It's just not gonna work. Okay, there's just too many hospitals here and the real, really hard work is not with the feds. It's not, Pat Jones is a real pro. She's been here a long time. I'm glad you're here, Pat. But the reality is that it's not up to the feds. The feds have no idea what to do with this. The real question is, can you, so the real question is, can this body, can you rationalize? Because you're the only one that has the power. The idea that one cared might have the power is a fantasy. You have the, you're the only ones that have the power that can rationalize that system. So good luck. Thank you. Thank you for your comment. Mr. Carpenter, Walter, how are you? I think you're muted, Walter. Okay, it wasn't on mute, but I turned it on and off again. Hey, oh, and I missed you for the last couple of months. Oh, I missed you too. Nice to see you. Denied my GMCB fix, weekly GMCB fix. I wanna just go back to Pat Jones' presentation and all of these models she was talking about. It reminded me of what Winston Churchill once famously said about America. That Americans will always do the right thing only after they have tried everything else. And every time we deal with a new model, we have to deal with another new model and another new model, because we're constantly doing everything else except the right thing. We're trying to avoid it. Another comment or question is the use of these buzzwords like equity, accountability, et cetera. How do you have healthcare equity when a hospital in one region charges a different fee for the same procedure, say a lobotomy, than a hospital in another region? And when prices vary so much because there's never really a fix on exactly what the price for this particular service is, as they can adjust it accordingly. How is the equity, if there is such a word or meaning for such a word, observed or maintained in a situation like that? Because we've been talking about equity for ever since I've been involved in this, which is like 2009 anyway. What exactly is it? That's just one of the buzzwords. And I think in our so-called free market system, you can't do that because there's so much variation in what a hospital or a physician's practice feels that it can charge. And when you have people charging $30 for an aspirin, a cost-recent, the incentive is to make as much money as you possibly can. How would you do that? And again, the real problem with our healthcare system, if you can call it a system, is not so much that we need a new model from business people at CMMI, which I think we don't need at all, but it's another story, is access. Is that we still have 44 to 50% for monitors, uninsured, underinsured, et cetera. And I don't see that problem going away with what CMMI is doing with this new ahead model. It's just like reshuffling the furniture. It didn't work this way. So let's reshuffle it that way while the ship is going beneath the waves. I'll leave it at that. And thank you, Walter. Any other public comment today? I think I actually had a comment earlier that I just really wanted to say thanks for all three presentations. They're very different and quite, just quite a breadth of those topics. So it's sort of hard to summarize them. But I think all three brought up some of these issues that Walter just brought up about equity and about the importance of hearing voices from Vermont and all corners of Vermont about what Vermonters want from their healthcare system. So I do think there's really a huge value to that. And I applaud the work that's being done. There's a lot left to sort out for the all-pair model and how that's gonna be implemented. But I really, I do appreciate that the participation in the advisory work, the advisory group that's going on, the technical group from lots of different voices. So I do think that we can work together to build a better healthcare system. It's a complicated system to work with but I'm optimistic with this work. And I just wanna say thanks for the presentations and all the hard work everyone's doing with this. I do agree about the public engagement. Thanks, Dave. Yeah, thank you, Dave. And as you guys all know, we really do appreciate these presentations. They were great, really timely and informative. And I'm excited for all this work. It's really, you know, Dave and I just got here a year ago, I think last week and this was all in motion and really critical to some of the challenges we're all facing. So thanks everyone. Is there any old business or new business to come before the board? And is there a motion to adjourn? So moved. All those in favor say aye. Aye. Aye. Aye. Aye. And the motion carries. Everyone have a great day.


us where I work in the main society and what I'm going to show you is going to combine a little bit I want to take you one year back to LGM Toronto and beforehand Dave Crossland was like, hey man you got to go to this session, one session and it's like, well, Nathan's session and so turn up and what was it about? Overdive features and especially about having UI for users to control over time features. Now we're going to do a little ratio of hands also this morning who is familiar with overdive features and size of all must be specialized audience that others wake up this I'm going to show some of them anyway what can I say about it's a lot of fancy replacements inside a phone and I'll just show it's a bit put your attention to the number system for instance these are the ones we know, petal height, motor space, proportional space, lower case numbers, motor space, in good phone there's four different numbers included in it. For example somebody with wild world alternates especially if you want to go in the direction of scripted and written phones you need variation you can do this in random ways in open type also so when it went mad with ligatures maybe maybe maybe the ones for three letters so that's just Latin and that's just a small part of it which part of open type features is this getting non-Latin languages scripts to display up here is the actual data input the actual text and will always stay like that but the display writes it's built the rules are built into the phone to a lot of substitutions reordering and then some moving around to bits this is how it comes out on the screen data rendering and it's quite a lot of that and it's more than 150 different scripts are supported Latin is one of them the rest of it is the more complicated stuff actually this number can only go up this number of languages that are defined because some of these rules are really language dependent where you do the substitution or not 390 this number can only come up you know so back to Toronto it was a really cool session where like 25 people in the room which in North America means it's about half of a LGM and we were talking about it and about that must be a library that supports at the end this UI for control and it turns out the library is hard for us and that's not quite a few people is the guy at the end of that session we all thought was a good the good thing if I if I was to work on this UI concept for open type features so get started and when you start this with getting goals defined in this call to vision so I realized in the online meeting find a list where everybody is and I was sort of expecting just like in Toronto it's going to be an exercise in crowd management 25 people in online meeting oh my god so who turned up even Nathan so there's already a clue in there where where this story is going I mean it was really grateful they were there because I don't define the goals that just help that the goals come out so look let's look at the vision it's in three parts you can start reading out infrastructure generally consistently available and platforms desktop tablet handle that's three different designs it left really the direct customer are on the application developers these are value points they don't have to get all this knowledge about topography etc that's what the solution is going to provide them last part end users anyone editing any kind of rich text here's the big clue why it's actually called by this infrastructure project it's just a super general everybody does it the scope I work really hard to get this part in like these users can actually benefit where they can find some value in this super easy to just shoot down the project that's a nice fancy extra but it used to be a bit of urgency into the whole thing and that's in a successful communication bit it all together shows that get a project on the rails and define them what you want to have out doesn't take large documents so let's move on to that infrastructure and over the years I've done a couple of projects in this in this domain the first one where cut my teeth was open printing Linux printing dialogues for everyone this project did not end well exactly for infrastructure reasons but it prepared me for the next one which was Nokia duals in which I must say is by far the most successful and satisfying project in my career so that was good I'm one there and for instance last semester was teaching about student projects that came up was multi-art space a guide now that word for people to take small spaces changes into atelier for one or more persons and also makes the space the guide aspect that is an infrastructure thing I learned some rules along the way that I like to share with you here and the first rule and the second rule of infrastructure is that you just don't talk about infrastructure is another rule that actually needs enforcement nobody really wants to talk with you about infrastructure it people actively avoid you if you do they find it really good that you take care of it but don't bother them it's very good this has a however one implication that one central way how people get rewarded working in close is having an active community and getting a lot of energy from that is why it's closed off in infrastructure I've learned that the hard way that means it's really only two other ways left one is you're on the mission from God you just want to do it nobody's going to stop you or the other one is it simply work that you need to pay your bills nice work but it simply just work second aspect everything's really unfocused there are basically no use cases because there are millions of use cases they're all equally important this really upsets people in projects and there are lots of them who can only talk by the use case this is really the usual way to but also for designers in design constraints are your friend they focus you and this is not there it's everything you can think of and beyond that everywhere does it there's nothing there to help you another aspect I've put here the three large components or trademarks the traits of a trait of a design project it's a structured process this is specification and then the build is a part of the actual of the actual project if you do it well everything feeds back into each other again this is how we do it in my extrapolator for instance but it's different in infrastructure is that you're going to get a direct result out there you're going to get a library guidelines and this is the deliverable of this project to get real results that people users can touch thousands of other applications need to do the whole thing again and the results of that are first guidelines 15 to this process and then finally down there you're going to get the result I'm sitting here trying to influence that or control is a big word includes that is the right one now also not that blue eyes so though most offers just got to be killed just like that you know if I know it and there even more the guide and the library is has to put these in order one thing that I learned that is really a trait of of infrastructure is that it's about a moment that different components meet maybe one user that goes his path with a plan you got a fault with certain capabilities you got an application that defines the main and at point where the meeting time I'm actually able to say what is a good UI to actually control those open type features and I'm sitting there a year before I'm not there at that moment so a general solution that you find in infrastructure is that the one person this user that's there on the spot actually has to put things right you do that through letting them configure their user interface at that point for their own for a week the trick is to let them configure it without them noticing the last thing I want to tell you a little about infrastructure itself is taking a while to find out that because infrastructure speaks for itself that it's there of course it works and it's for everyone that everybody's thinking explicitly implicitly who should provide it that's the answer this is what's killed open printing was just a giant game of chicken between all the parties like it's going to actually pay for the work do the work etc turned out it wasn't opening its government so I could feature themselves some problems and maybe solution some point that this instead of talk about uh yeah we don't know uh there's really little support in any application for controlling this so you don't know uh or that makes that supporting them in the false themselves so very people do it is yeah it's actually very an underdeveloped area and you kind of design things for how things are right now you're going to enable capabilities and at that moment the usage is supposed to really shoot up but also the number of faults supporting it and that's the situation you've got to uh design for so don't design for where the puck is now but for where it's going there's a lot of features different features that need to be controlled you could have a black and white discussion about that is it going into the UI this feature or not a lot of backshedding or you think it shades of gray three shades of gray and you number this level one two three on the first is what implements that vision communicating text aesthetics and typography the bottom is this thing of making scripts working that you saw with the the monogamy and in the middle is what is left over so you start chopping off those 135 into regions and then you can really say okay not UI fully UI splitting of the features still too many that you have to put into UI taking out mutual slipper stuff still too many so we really have to do a still a vast reduction in the amount of stuff to show so I'm going to speed up a little bit one of the design problems that will pop up is that look at these segments they want to reflect the state is this involved in analytics the answer is partially but not at the same time it's this reflecting what is set and showing what what is going on it's going to be this is just for two things it's going to be a lot more difficulty you got a lot of selected text then there are 135 things to reflect and how to do that to add this talk what's going to happen from now on now in a way the situation is clear the situation is clear that actually the situation is difficult and it's not the design problems so I'll skip that one for you that makes it makes it difficult I love solving those problems etc but it's actually those infrastructure aspects that I talk about these forces that actually stop the project that makes all the features for everyone makes it very difficult to move forward there that's what I want to say today thank you


You two team keep it clean. What's going on? It's engraving here with another video and in this video Whoo, these preseason injuries starting to rat Well, they're not even starting to rack up because they have been racking up for a long time now Just came out like about maybe 10 15 minutes ago that the Patriots where I received a Julian Edelman He suffered a knee injury in the preseason game against the Lions. What's up tested? Now with the knee injury Or really with any injury There's a very scary part about this injury with Julian Edelman and we're gonna get into that right away But first and foremost, let me introduce myself me. I mean graven vids. This is my youtube channel engraving vids And me I'm a Ravens fan. I know I got on the Patriots jersey, but I Talk I love my Ravens to talk about them all the time But we also talk about every single team in the NFL and this video is no different than those Appreciate that Donovan. Thank you. But If you a fan of football if you fan of the Ravens or you a fan of any team in the NFL Make sure you subscribe. Make sure you subscribe to the youtube channel Turn the notifications on so you don't miss anything for the people that are new here Thank you for joining us and for the people that are old here. Thank you for continuing to support us We appreciate it man. Thank you seriously And also make sure you leave a like on the video. Thank you for congratulations congratulating congratulating me on the 6,000 subscribers that is a That's a big milestone for us, but it's not the end. It's just the beginning. Hopefully hopefully we just continue to grow And I've been appreciating everybody that comes to and everybody that's been a part of the channel Well, make sure y'all leave a like on the video to is 20 people in here, but only 10 likes. What's up, Nathan? What's going on everybody? What's up Seth? What's up, right Porter SSG Devon chips Donovan Chase Malachi Everybody that's up in here. I appreciate y'all man. Thank you. Um, anyway The Patriots Julian Edelman said 10k by week five. Hey, we'll see man. That'd be nice. What's up Jordan? What's up, Kate? But anyway with Julian Edelman what I was talking about he suffered the knee injury after he caught a pass against the Lions Now what the most scary part about that is What the most scary part about that is is not that he has any injury But it's the way that he got the knee injury It's the way that he got it because he caught the ball. He was running turning up field and then all of a sudden He just failed and the scariest part about it was that it's a non-contact injury a Non-contact usually the non-contact injuries those are the worst usually though appreciate you subscribing Seth usually the non-contact injuries means Season is done usually not all the time But usually about 90% of the time non-contact injuries mean that's it Season is over and that will be a huge blow to the Patriots because Julian Edelman is somebody that knows the system He plays it well. He does this thing But They would still be fine Because Patriots are a team that is known for They boy, they know about next man up better than anybody when it comes to the offense when it comes to offense They know about next man up better than anybody because they can put any receiver in there. You can be the slowest Receiver in the world You don't have to have all the speed you don't have to have all the height You don't have to have all this ability all you got to do is know how to run around and be where you need to be and catch the ball And that's it Tom Brady'll make you look like a superstar. It doesn't matter who it is, man Yeah, turning janitors in a pro bowler. That's the Patriots way. That's when there's Darcy. That's it flood time So what's your sub goal? I don't I never really thought about that. I mean, I would like to do it for a time I guess that would be the answer to your question if I could do this for a time I would love that to do this and do my madam video for time that'd be great So I guess that's the answer to your question on what's my sub goal But anyway, yeah, man Non-contact injuries are the worst when when you ever hear of a player getting hurt in a walkthrough a walkthrough It's not physical practice. Whenever you hear of a player getting hurt in OTAs It's it's tough. That usually means it's a wrap that usually means it's a wrap man That that's what it usually is. That's how it usually goes For Julian Edelman, we haven't got any confirmation on it yet, but we'll I'm sure we'll be seeing soon I appreciate that flood time. Thank you I just put out a put out a bunch of madden videos today actually and I just put one out versus on my boy launchpad 1412 So y'all gotta make sure y'all check him out to check out that video. It's the video That's right before this one. So yeah, once we find out about Julian Edelman If some if we get whatever kind of news we get whether it's gonna be good news or bad news This is what I always talk about that is the absolute worst part about football the worst part about football by far And it's not even close is injuries.  I hate it I don't even care if it's on a Patriots team, which I which I don't like at all But I do respect the game and love the game of football. So I love seeing competition I love seeing the best players out there and it sucks even if it's not the best players that get hurt It sucks that people have to get hurt in football. It's tough. It's tough So it's tough Yeah, they did sign Brandon cooks from the Saints. They did. Yeah, and like I said earlier Malik I said they got cooks ground hogan. They have players and they're gonna be fine Whether season ending or not, but it still sucks.  That's the worst part about football so Anyway We'll see what happens. I'll keep y'all posted once I find out what happens I try to let y'all know that once y'all find out what happens y'all can let me know either way But I appreciate y'all watching thank you all the new people that are here make sure you subscribe all the old people stay subscribed And hopefully it ain't really anything serious with Julian Edelman Even though I really think this season is probably gonna be done cuz like I said non-contact injuries They're always tough. They always are the worst. I can't do a madden live stream right now Because we got family over right now, but um if I could I would but I can't right now Anyway, um, do I got the pass in a Super Bowl this year? No Um, I said Raven Seahawks, but yeah, appreciate y'all man. Thank you. All right, Sheila. Enjoy yourself Appreciate y'all ways coming through with those those thought-provoking comments. Thank you Everybody's up in here. Oh perfect one. What's going on man? What's going on? Hope all is well with you man and the family But and like I said look look forward to the game tomorrow. Oh, yeah, Malachi. You should be high What's up, Link Craft? How you doing man? I ain't forget about your Jaguars depth chart video. Don't worry I ain't forget about it. I ain't forget about it at all. They did Fleck O' Dirty and Madden. Oh, Fleck O's terrible last year So his rating doesn't need to be high But yeah, appreciate y'all watching. Thank you. Like I said once we find out something I'll let you know and we'll all get updated together Anyway, make sure you leave a like on the video if you haven't done so already and subscribe to the YouTube channel If you haven't done so already. Thank you chase. I appreciate it and also What make sure y'all watch that madden video that I just put out make sure I just put it out the Thumbnails Eli Manning on the front. That's how you know it's me Yes week one We like two weeks away. It's coming. It's coming soon So to be here before we know it but anyway, I'm getting off of here for real this time I've been saying I'm getting off and I'm actually getting off For real now. So appreciate y'all if y'all want to follow me on Twitter snapchat Instagram Everything is engraving vids just like the YouTube channel. So I appreciate y'all man and That's it. Once I find out I'll let you know and that'll be that appreciate it. Thank you


Can you scabies or something? You give me fleas. Because I love you.  I'm Corbin. I'm Fleas. Uh, please follow us on Instagram! I'm Tudu! I'm all juicy content! I'm Joe, juicy. I love to play with the juiciness. In two days. You do have fleas. Here, that's why I didn't choose. Oh. Uh, and thank you for just wanting to send me a picture. We love that. And love you.  Uh, and follow us on official Twitter account, because thank you. Here's Pudence. Uh, and... What are we doing on? I don't know, what are we doing? I don't know, I never know. I just show up and you tell me and we do it, and I'm like, yeah, rock on. Traylor! Oh. It's called Madras... Madras Cafe. Yes, I think it... It's either that or it's... Madras. I think it's Madras. And, uh, I believe this is about the freedom fighters. I could be one. Sweet. Like the freedom fighters we were first introduced to through... Yeah, uh... Bangor Rosanti. Okay. But, uh, I think it has John Avery. Cool. Uh... Which reminded me, man, we've got to watch a full film of his. Yeah. Uh, we've got a long thing to do and to watch and we're gonna get to it. But... Come on on! Here we go. Criticizing our national policies doesn't make me international. Who in the city, oh God, can't it just work in? I am not playing KCW. I'm here because there are human lives at stake. You're all mistaken. Yes, I'm mistaken! Why are these for Deca? For whom do you work? Ruby will go on operations. It's a leak! The support team has gone from 4 to 5. I mean, we've got to strike tonight. And he is a national threat. Raj Shikran did have crucial meeting at Majore's cafe. I don't like liars. Simply because we're not safe here. I'm not safe anywhere else. We're negotiating. Suspicious activity on the scene. Ask them to hit him. Well, maybe she's grown... as an actress. Because that was her first. Right. Rockstar was her first. How much has she done? She's done a lot of work since then. That was her second film. Majore's was her... This was right after Rockstar. She got a lot of like... How did she be... How did she... It's relational. That's being, man. It's relational. But anyways, let us know... Let us know. How is this film in general? The trailer looks great. Where are you from? An Indian intelligence agent journeys to a war-torn coastal island to break a resolute rebel group and meets a passionate journalist. Yeah. It reminded me a little bit. That aspect of it. Her being a journalist and wanting to report to him being what he does. Had shades of... Blood Diamond. The Caprio's relationship with the journalist. But just shades of it. It felt like Apocalypse Now at the beginning with the helicopters and no Vietnam film. But I know it's not. It is the director... Shoot it. The director of Pink. Pink. Yeah. Vicki Donner. Vicki Donner. Piku. Well, maybe he didn't direct that. Or did he have stuff? Yeah. Director of Piku. Yeah. Director. Director. Director. I have high hopes for her working with him. Sincerely. Let us know. Yeah. Please let us know. Very high hopes. And this is John Abraham, of course. Yeah. It looks great. Yeah. The trailer is phenomenal. Great trailer. I like to look at it a lot if it's a true story. Who did the score? Because the score for the trailer is the same as the person who did the... Because sometimes it doesn't happen. It doesn't mean, you know, a composer can do the film and then someone completely different does the trailer. Now, most of the time it's the same person. Let me see if he's the same person. Composer. October. Pink. Pink. Composer of Peacock. Yeah. Good composer. Good stuff. Trying to see what else.   You've done a lot. You love that album. Yeah. Love that. Love the music and three idiots. So, yeah. This looks... I mean, it was highly requested. Especially once we started getting into some of John Abraham's stuff. Should this be one of our firsts? Let us know what should be our first introduction because obviously we saw him in Senkuma. Right. And I'll tell you what else was impressive in this film that he leads. Impressive in this was the sound editing and sound mixing. The breaking glass, the gunshots, the ricochet. Yeah. Just everything looks... Similar, like, style to like... What's that film? With... They're in Vietnam. Platoon? Yeah. Platoon style. By the way, I see some... A lot of comments sometimes will say, you know, don't compare it to this. Irrespective. It could be an American film. Like, one time we were compared something and said it reminded us of KFG. We have to compare it to something that's our frame of reference. And if it reminds us of something, it's not either a compliment or a derogatory statement. It's just... It reminds me... Most of the time it's complimentary. It reminds me of this in a favorable way. Unless this reminds me of Student of the Year 2. And then that's obviously not so good. But yeah, I mean, it looks really good. I'd be totally interested in seeing this. If you say it's not... If you recommend it. If you say it's not, and she's terrible, then... Yeah, that would be my biggest concern. But the fact that she's working with this director speaks volumes to me because I know what he did with Piku and the work that he got out of Topeka, who similarly came into doing film with no history of acting at any time. I didn't compare her to Topeka. I wasn't comparing her to Topeka. I'm thankful that she's working with this kind of a director because the performance that he got from Topeka in Piku was beautiful, especially that scene where you've seen the behind the scenes with the knife and the trunk and the way they all work together and the improv that took place and her... I mean, he got her to improv comfortably with... Oh, she's a phenomenal actress. Yeah, I'm not saying she's not. Don't compare her to that grief.  Imagine if I compared her to Alia. That's more actually acceptable. They're both phenomenal actors. You compared her to this girl from Rockstar. No, no, no. If I compared this girl to Alia. Oh, yeah. Not Topeka to Alia. Her to Alia. That's still insulting. It's just as insulting. And I wasn't comparing her to anybody. I was saying I'm thankful she's working with the same director who brought the performance he brought out of Topeka.  Why do you do this? Just give up the stupidity.