Good afternoon and welcome to the Green Mountain Care Board. My name is Kevin Mullen, chair of the board and I'm gonna convene this meeting. First item on the agenda is gonna be the minutes of Wednesday, July 28th and Wednesday, August 4th. Is there a motion? So moved. Second. It's been moved and seconded to a few minutes of Wednesday, July 28th and Wednesday, August 4th without any additions, deletions or corrections. Is there any further discussion? Hearing none, all those in favor of the motion please signify by saying aye. Aye. Those opposed signify by saying nay. Thank you. Next I'm going to call on Michael Barber, our general counsel to announce a couple of rate decisions. Mike. Thank you, Mr. Chair. So I need to announce the board's recent decisions on the 2022 individual and small group rate filings and probably should just start with a little bit of background. So as a result of legislation that passed during the most recent legislative session the individual and small group health insurance markets in Vermont were unmerged for 2022. And this meant that Blue Cross and Blue Shield of Vermont and MVP health plan each submitted separate filings for their individual and small group plans. Unmerging the markets had the effect of lowering small group rates and increasing individual rates compared to what they otherwise would have been with individual rate increases being offset by expanded premium tax credits available as a result of the American Rescue Plan Act. So starting first with individual plans based on the filings, there are approximately 31,000 members covered by these plans with membership being split pretty evenly between the two carriers. Blue Cross requested a 7.9% average annual increase for its individual plans which it lowered to 5% based on the recommendations of the board's contracted actuary. And then they increased their request to 5.2% following the submission of hospital budgets. The board approved a 4.7% average annual increase for these Blue Cross plans. MVP requested a 17% average annual increase for its individual plans which the board reduced to 12.7%. Moving to the small group filings, according to the submissions, there are approximately 40,600 members in these plans with 21,858 members enrolled in MVP plans and 18,755 members in the Blue Cross plans. Blue Cross proposed a rate change of negative 7.8% which it increased to negative 6.4% based on the review conducted by the board's actuaries and then increased that again to negative 6.2% following the submission of hospital budgets. The board approved a rate of negative 6.7% for these Blue Cross plans. MVP meanwhile proposed an average annual rate increase of 5% for its plans which the board reduced to 0.8%. So I know that was a lot of words but it was a little complicated this year by the four separate filings. Thank you, Mike. So next on the agenda, I'm gonna turn it over to Executive Director Susan Barrett for an update and also I'm gonna ask Susan to introduce our presenter and presentation this afternoon. So Susan. Great, thank you, Mr. Chair. And thank you, Mike, Barbara for getting that announcement out. I'm glad you were doing it today and not me was very complicated. So I want to remind the public that next week the board will start our hospital budget hearings. They are all going to be accessible via teams and we do have a physical location at 144 State Street in Montpelier to comply with the open meeting law. I will mention that all board members, staff and presenters will be presenting via the teams remotely. We have a couple of ongoing special public comment periods. One is related to and is about the FY22 hospital budget submission. So on July 28th, 2021, we opened the special public comment period for the FY22 hospital budgets. This will go through September 1, 2021. As I mentioned, the hearings start next week and then the deliberations for these decisions start September 1, the board will make a decision on the hospital budgets no later than September 15th. So we ask that folks submit public comments prior to September 1st to be considered by the board in deliberations. The second ongoing public comment period is on a potential next agreement of the all-pair model with CMMI. We opened this comment period earlier this year and we continue to take these comments and we ask the public to please provide these comments. We are sharing anything on that potential next agreement with CMMI and any public comments with our partners at AHS and the governor's office as both AHS and the governor's office are taking the lead on the negotiations for a potential next agreement. So with that, I will move to introduce our speaker today and give you a little background. Today, we welcome Shuley Garovitch who is a senior fellow at Mathematica Policy Research Group. She'll be presenting to the board on avoidable utilization in rural hospitals. Before I share a little bit of background on Shuley, I wanted to mention that her presentation today adds to the ongoing work and discussions the board is undertaking on rural healthcare sustainability as the Centers for Medicare and Medicaid Services, the state of Vermont and by virtue of that, Vermont's hospitals transition to value-based care. And as such, these hospitals will be more increasingly accountable for cost and quality. We want to ensure their sustainability in this value-based world. I think the presentation today will talk about ways to do that. And I hope that it will inform both the board, the public and our stakeholders. So now I'll transition to introducing Shuley Garovitch. As I mentioned, she's a senior fellow at Mathematica Policy Research Group. She's a lengthy bio and I won't go through everything, but I think I'll pull out a couple of things that may, I think are very interesting for our discussion today. So Shuley manages the state health policy portfolio at Mathematica and she's an expert in healthcare payment policy alternative payment models, global budgets, all payer models and quality and performance measurement. She has a really extensive experience with state health policy in Maryland, Pennsylvania, here in Vermont, of course, in Massachusetts. Shuley, I actually met Shuley years ago, I don't know, maybe five or six years ago, when we were just really exploring the potential for an all payer model, Shuley worked at Maryland's and I know I'm going to get, maybe I'll get it right, the Maryland Health Services Cost Review Commission for many years and her expertise, both in data analysis, quality metrics and the work she did down in Maryland really informs her work that she does for states today. I will also mention that Shuley also has a clinical background having worked as a clinical nurse for six years in inpatient settings. She also has a PhD in public health from Bloomberg School of Public Health and an MPP, Masters in Public Policy. I hope I have that right from the same university. And there's more, but I'd encourage folks to look at her bio on the Mathematica Research Policy website to learn more about Shuley, but I think I will turn it over to you, Shuley, to share your presentation. Thank you for coming today. Thank you so much, Susan, and thank you for that introduction as well. Can you hear me okay? We can hear you. Great. Thank you for the invitation. Yeah, I think it was about six years ago. What I remember is you all came down to Maryland to talk with us and I had the terrible franchisee, so I ended up not being able to talk with you, but I'm glad we had the opportunity to meet in person and I really enjoyed working with Vermont and thinking about these challenging issues. As a kind of person who worked with multiple states, maybe my perspective on Vermont, I'm gonna start there and then we'll go to the presentation. Vermont is one of the three states who are really at the trailblazing end looking at the reform, both from the delivery side and from the payment side. You have been in the long journey, you know, blueprint and before that medical home models. So you are far ahead in this journey compared to many other states. And the way that Vermont is dealing with sustainability and rural health is an advanced model and I'm hoping that it will help other states as well as you work through these tourney issues and create a sustainable healthcare finance for rural health. So with that, I'm going to see if I can share my screen and turn to the presentation mode. Okay, can you see my slides? Yes, we can, yep. All right. So I wanted to start with a little bit about Mathematica. As Susan mentioned, we've been working to support GMCB around all peer model monitoring reports, but Mathematica has been supporting public and private sector policy makers over 50 years and our strength is really bringing the data and the policy makers together to think about how we can use analytics to improve healthcare and social services. With this mission orientation to improve public well-being, we've been working in what we call a data lab. Data donation lab is aiming to bring the data to the decision makers and looking at variations in total cost, quality, and access, both from the payer perspective, provider perspective, and population perspectives to help with the healthcare reform that we are here to discuss a little bit today. We process the national Medicare and Medicaid claims and we are producing publicly available reports on our websites from our work. There is about 10 people who are working on the innovation lab with me. I won't go into the details, but I just wanted to acknowledge the team behind me who really worked hard to create this dashboard and published it on our website. The interactive dashboard is focusing on rural health. As you all are aware, we have tremendous challenges and disparities in rural health, both in terms of access, high burden of disease, as well as high quality of care that is provided to this population. So we focused on rural health for our dashboard and wanted to give information to help decision makers how to think about value-based payment models and create new models to bring the delivery reform and the payment reform together. Our goal and our audience is really hospital executives and hospital policy makers. So a lot of the information that you're gonna see today is thinking through the policy levers that we could use to improve the care and provide high quality care in rural areas. So I'm gonna go into a little bit details. So what we did in this dashboard is we measured avoidable hospitalization at rural hospitals. So what does that mean? So this is a concept that has been used in many states and it is defined as a unplanned care and it is a care that we think would be prevented if we have a better ambulatory care settings. So I wanted to give you a perspective with the other measures you may have heard as we are thinking about healthcare reform which is termed waste or unnecessary care. I wanted to make a distinction here. What we are looking at here is an avoidable utilization. It is really tied to population health. So it is not unnecessary once we arrive at the hospital door and from my experience with the inpatient care, this is very true to my heart. When you are at the hospital, you definitely need that care. So we are not talking about unneeded care or waste. What we are talking about here is a population health based utilization where really if you look at these measures we could design population health centric policies and reform to improve and reduce avoidable utilization at the hospitals. The measures are based on claims data. So these are the billing statements provided by hospitals to the payers. And we flag these claims into three categories. One is readmissions within 30 days. Second is ambulatory care sensitive admissions. So those are two inpatient measures we have. And the third one is looking at the emergency department visits and looking at avoidable emergency department visits that are not admitted into the inpatient setting. So I'm gonna go into detail a little bit what these measures are and how we modified it for this purpose. The first measure is a 30 day all cause readmission measure. You may have heard about this measure in other settings. Federal government as well as private payers have been using readmissions as a quality measure for hospitals and adjusting their payment rates based on whether they have high readmission rates or low readmission rates. The measure looks at whether the patient is readmitted to the hospital within a 30 day period of their initial discharge. The idea behind is that if there is a care coordination and support services for the patients following their discharge, they should not be coming back to the hospital and those admissions could be avoided. The measure is validated nationally by NCQA and it is also used in the HEDIS measure sets for the private plans. It excludes plan service lines such as pregnancy, prenatal care conditions, transplants, rehabs. It's really looking at the admissions where we think that with the care coordination and better primary care, these admissions could be prevented. For our purposes, since we are looking at hospital finance, we only count if the patient is coming back to the originating hospital. So this is a subset of the readmissions that the quality measures look at because in our terminology, we would like to give the hospital executives an idea of how many of their admissions could be prevented that are coming to their hospitals and originating from their hospital. So the idea is the patient is using a rural hospital as the main source of their hospitalizations. The next inpatient measure is ambulatory care sensitive conditions. This is again, another nationally used measure by ARC. It is also called as Prevention Quality Indicators, PQIs. As the name suggests, it is focused on prevention and ARC calculates these measures at the geographical level. So they do have reports looking at county level, PQIs, measuring all admissions for the residents of that rural county or urban county. The idea behind these measures are the, if you look at the conditional list that I listed here, these are all chronic conditions and with a better care management and prevention public health interventions, these admissions would reduce at the hospitals, diabetes, COPD, hypertension. So these are all chronic measures where we do have some evidence that with the prevention and public health, we could reduce these admissions at the hospital. So we took those two algorithms and created an inpatient measure for avoidable utilization and looking at the percent of revenue that are coming from these two measures in the inpatient side. Emergency department visits are in other places where we could look at this concept and look at avoidable utilization. And here we have a somewhat of an old algorithm developed by New York University about 20 years ago. We adapted this algorithm and updated with the new ICD codes. But in this basic algorithm, it is looking at the primary reason or diagnosis for the ED visits and creating a three different classifications for ED visits. The first one is non-emergent care. So those are the conditions where they really didn't need the emergency department but for various reasons, they showed up in our ED departments. The second one is emergent but primary care treatable conditions. So there was an urgency for the condition but if they had better access to primary setting, we hypothesized that they are not gonna be coming to the emergency department. So this is a good example is ear infections for kids, right? So those kind of urgent care conditions could be treated at the office setting rather than emergency department setting. And the third one is an emergent ED care needed. So this is the highest level of visits where we do know that the ED was the appropriate setting but again, with a long-term planning and effective care, those conditions could also be prevented. So those are the three measures that we have in our dashboard. And before I go into presenting some results for Vermont, a few other details as you're looking at the results. The first one is what we present here today is a results from Medicare few for service only. So this is the traditional Medicare plans. And when you look at other payers, Medicaid or commercial payers, what we see is the Medicare population has the highest utilization rates in avoidable utilization. And reasons are multitude, but as you know, the chronic conditions are more prevalent in the Medicare population. And in the few for service environment, the coordination activities are limited to manage these conditions in the ambulatory setting. The second information is we are really looking at revenues. So these measures are not a reflective of the hospital's performance. So I just wanna repeat that again. We are not looking at hospital performance in these measures. What we are looking at is the impact of the area that the hospital is serving on their revenues. So if you are a hospital or a policymaker and you're thinking about value-based purchasing and financial opportunities for these hospitals to improve population health, this is the revenue impact of those potential value-based purchasing that I'm gonna get into towards the end of my presentation. It is not risk adjusted. And when you compare hospital to hospital, we also need to be very careful to think about what other services hospitals are providing on the outpatient care. So the revenue percentages are impacted by the denominators as well as the actual counts from the avoidable utilization. We included hospitals located in rural areas. So this is defined by the Federal Office of Rural Health Policy. And some of these hospitals could be large hospitals serving not only the rural areas, but also the urban areas. So I wanted to point out that. So the rural definition is really based on the location of the hospital, not the people that they are serving. And finally, as there is an overlap between inpatient measures on the readmission and PQIs that preventive quality indicators, we counter them as a PQI to reduce the duplication and have an accurate percent on the revenue. So if you have other information around readmissions, you may think that our readmission rates might be low. And that's the reason why readmission rates might be lower than the PQI. So we can't really judge whether they have a higher readmission rate versus a higher PQI rate. So this slide is the hospitals that we flagged as rural hospitals in Vermont. And it is showing the percent of revenue in avoidable utilization on the inpatient side. We separated the readmissions from PQI. And as you see, there is a wide variation in both measures as a percent of revenue. Just to orient you to the results, the highest ambulatory sensitive admission percent is with Grace College Hospital with 33% of their inpatient revenue in avoidable utilization in PQIs. When we look at the pink columns, it's looking at the readmission counts. And here the range is between 7%, the lowest at Radleboro Memorial Hospital to 14% in several hospitals that are shown towards the end of this table. The second one is the emergency department. So here you have a much higher percents. And if you think about the ED and the ED utilization, this is not surprising to us that over 30% of the ED utilization is potentially avoidable. And when we bring together inpatient and ED, what we see is that the floor of this is around 20% and the highest are around 37%. As you're thinking about your hospitals and sustainability in the value-based purchasing, these are the potential opportunities depending on how you structure value-based purchasing with these hospitals for them to improve their community access and work with the community providers to reduce avoidable utilization. So you could think about it that way, as well as the utilization declines in these hospitals as a result of these value-based purchasing, it creates challenges for the financing of these hospitals and how to maintain access to care in rural hospitals. So from there, we could think about different policy applications of these results and how you can think about utilizing a data-driven approach. So as we talked about the value-based purchasing, we are witnessing a different models in alternative payment models. And they are different based on the specialty or the type of provider. I provided two examples based on the specialties for primary care. We have medical homes emerging in a lot of places and it's been a more over 10 years development of the medical homes models. We have accountable care organizations and you are all familiar with your old payer model how accountable care organization really bridges the gap between primary care and specialists and hospitals. And for specialists in hospitals, there are also episode-based models which look at hip or knee replacements, for example, and how we can create efficient and coordinated care focusing on special procedures or special episodes. What is common across all these models is our goal is to create incentives that are aligned to provide better coordinated care and high-quality care. And the cost savings from these models are usually coming from reduced hospitalization and better post-secure care utilization to avoid hospitalization. So a lot of the work and the literature up to date is looking at the savings from hospitalizations as well as post-secure care utilization. So if you think about what I presented earlier, I created this two fake examples. So if you have a model in aligning financial incentives and you are trying to coordinate care and reduce cost, we have two examples here. Hospital B is about 25% avoidable utilization in their revenue and hospital A has about less than 20%. So if we are trying to improve care, which hospital would you focus? Hospital B has more opportunities, but it could also present more challenges in terms of the social determinants of health, access to care, and the ambulatory setting. Hospital A has lower opportunities and it may also have similar challenges or that there may not be additional improvements that we could expect from hospital A, given their low utilization rate on indovoidable utilization. I copied the slide that I like a lot in terms of where we are and where the payment models are moving towards. As Susan mentioned, we are working towards creating new designs for the finance and move our system from fee for service to what the federal government and the private companies coordinate as the population-based payment models, which is category four. So in this models, what we have is a classification of financing from fee for service, which is the category one to category four, which is considered to be the most advanced payment models that really looks at population health and provide incentives for providers to coordinate care and removes the barriers of the fee for service, which is fragmentation and getting paid for doing more rather than preventing and improving population health. As you can imagine, fee for service creates this challenge for our provider community. On the one hand, finances are dependent on how many admissions you do or how many ED visits you have versus the medical community where they focus on patient needs and try to improve population health, which in turn may reduce hospitalization and admissions and impact the hospital's finances adversely. And we see that in the rural health very starkly. So this graph shows the hospital closures in rural areas and looks at the prior to 2010 versus 2010 and onward. As you see, we have a lot of yellow dots in our national map. So these issues are not unique to Vermont. So we are observing a national trend in rural hospital closures. And there are multiple reasons why we are seeing this trend increasing and we may see actually even more closures in the future. But there are very significant impact of rural health hospital closures to their community. And from there, our take on message is we really need to think about this collectively and merge the delivery reform with the payment reform and the PAUs could provide a data-driven approach for us to create some alternative models and work on sustainability. In these new models, we need to focus on community needs and improve access. And data in the PAUs has been providing a couple examples and how they structured their payment models using this data. So the models that are using PAUs from this perspective are three. The first one is in Maryland. That started as Susan mentioned when I was in Maryland and this is again a 10-year period for Maryland that we started working with the first rural hospitals to create global budgets with the rural hospitals in the state and later we created these budgets for urban hospitals as well. And in the latest stage of the Maryland PAUs, we are now focusing on improving total costs and trying to align payment levels between hospitals as well as physicians and ambulatory care setting. The other example is Pennsylvania Rural Health Model which started five years ago. And this model is really focusing on rural health and leveraging the state to coordinate the policies across commercial and public payers. And the most recent example is coming from CMS. CMS instituted a new model called Community Health Access and Rural Transformation Chart Model. And building on the experience from these two states, they created two tracks. One is a global budget for hospitals and providers in a community. And the second one is Accountable Care Model which takes some of the lessons learned from Vermont as well as some of the other rural health models that CMS ran in the past. In the CMS model, they are requiring the convenience to work with other payers and they are looking at, especially the Medicaid departments in the state to coordinate and recruit private payers and bring Medicare, Medicaid and commercial plans around global budget for rural areas. What is a global budget? And there could be different names but essentially global budgets are fixed revenue models. So you establish a revenue base for the hospitals. And in this revenue base, it's usually based on historical revenue. And you adjust the revenues, not only how many patients they treat, so you adjust the global budget based on quality efficiency and adjust for shared savings with the payers. So the fixed revenue really takes the equation to a new level and it is not a claims-based fee-for-service payment, but hospital receives a set guaranteed revenue for the full year and create transformation plans to improve population health in exchange. How the PEUs play in the fixed revenue? So I provided a very simple but complicated graphs in this example. Again, if you remember our hospital A and hospital B, we have a two scenarios. We have a 10% PEU in hospital A and in hospital B we have 20%. All hospitals under fixed global budget is going to receive $100 as a fixed revenue in this example. And based on their PEU levels, hospitals would save and create opportunities for population health improvements if they reduce their PEUs under global budgets. As they reduce their PEUs, which are the red arrows here, they get to keep the revenue because their revenue is set at $100. For from the payers perspective, how to ensure savings to population and reduce our rates? We would create shared savings looking at this targeted avoidable utilization reductions and gradually reduce the revenue percents from $100 in the first year to incremental changes to ensure that the savings are shared with payers and the population. So in both Maryland and Pennsylvania, potentially avoidable utilization have been very critical to help hospitals to create transformation plans, look at their data and understand where the community needs are. So they've been doing detailed analysis of the top conditions that their hospital is receiving in avoidable utilization and working with their communities to create new services if they are required or change their practices to ensure that the care is coordinated with the goal of reducing avoidable utilization over time. So with that, I will stop here and answer any questions you may have. Kevin, you're muted.  And you gave me a heart attack. I'm like, oh my God, was I disconnected? Sorry about that. Thank you so much, Julie. That was a lot to digest in a short period of time. And I'm gonna open it up now to board questions and comments. And I'll go in reverse alphabetical order starting with Tom. Yes, a lot to digest. I mean, my mind is going between this presentation and the reality of how hospital budgets are staring me in the face every day these days. I don't quite know where to start with questions because there's so many. But first at a practical level, have you worked with any individual hospitals where these concepts have been applied and where the results are clear and can be pointed to? Because I find that this concept here of the two canoes with a foot and one canoe and a foot and the other that generally, whether it's insurers or providers, they prefer the bigger foot in the fee of service canoe. Everyone seems to genuflect to the concept of quality care and fixed payments of some sort, capitation of some sort. But it just seems to be in a small corner of the world and not getting a lot of momentum and growth. And I think it would help if there are specific hospitals that we can point to say to our hospitals and to our providers, look at here. Here are examples of where we can be. Wow, great question, Tom. So a couple of things. So I think the longest experiences with Maryland global budgets, you are right. So we talk about value-based purchasing and fixed payment, but until we fix this issue with getting paid on a fee for service versus having this marginal value base, right? At the end of the day, what we saw with the readmission quality adjustments that CMS implemented, they were getting dinged by small percentage of their revenue. They couldn't afford to lose the readmissions from the finance perspective, right? And it is a reality and it is the rational thing to do if you are get paid on a per service. In Maryland, we have as a regulatory agency, we have collected a lot of information what hospitals that once we established global budgets. Setting the payment model is not enough. It is a culture change. What we experienced with Maryland in the initial years was even though we thought that the incentives were aligned, culture wasn't there yet, right? So it takes a while for hospitals to leave that canoe and jump fully into the value-based world where you look at your services from a very different perspective. There are very good examples in Maryland and I'll be happy to connect you with a few of them that implemented that strategy. They used data and they looked at their ED utilization and they start tracking which patients were coming for what purposes and they created additional services to support these hospitals. Some of them did social determinants of health and they are working with kind of reducing prescription drug cost or creating some food support for their patients to reduce again hospital utilization but they are guaranteed on the revenue side, right? So that's the big one that kind of changed the way that they implemented their services. I guess if a lot of provider community is hesitant on the value-based purchasing, I'll say even if they are not participating in those, it is coming as I pointed out, all other models are looking at hospital utilization as a cost savings. So if you don't implement value-based purchasing involving hospitals at the end, especially for the rural health community, we are gonna be in a place where hospitals would start closing and who's gonna provide services if the major employer and the infrastructure is gonna disappear without any sustainable model. So whether hospitals do it themselves or somebody else to do them is the conversation that you may wanna have with the hospitals to understand what their perspective is. Finally, one model that is kind of getting me into that direction is CMS started a new model called Drake Purchasing and the details are many, but the idea is to create contracts with external entities for them to start thinking about this providing services and purchasing them directly from the providers and that is gonna create additional financial pressure for the provider to negotiate and kind of do analysis like we did to create the per member, per month type of analysis to reduce cost. So whether hospitals are in or not will become irrelevant in a way because this is the field and it's going towards as I showed you in the graph towards the population-based models and it will come five to 10 years to everywhere. So based on just your observations, I think in the last year, the board has spent some time trying to nail down what the quote unquote tipping point is for value-based payments where these reforms begin to yield the kind of benefits that everybody hopes for. And so we put a condition on our ACO to get us a report in that regard and they've submitted a draft I think and staff is scrubbing it now. But do you and our hospitals we can see have been pretty flatlined for the last two or three years that around 14% in terms of their revenues being the broadly defined fixed prospect of payments. Capitation rates are much lower but broadly defined was some kind of rich sharing or something of that sort. It's in the 13 to 14% range. Do you have any sense about what a, as this thing unfolds, value-based payments unfold where the tipping point is, where hospitals or providers can begin to say, Eureka, this is working. Value-based payments is working. We do a lot of evaluations at Bathmark of the federal models. So I would kind of need to talk with them a little bit on the tipping point, but from my side, like one is about the impact of those models, right Tom? And it takes time. So it does take a few years for the implementation to get into the levels that we want them to be. It has to be at the patient point of contact. So it's a little bit of a time question than a tipping point for flipping the switch and declare that value-based purchasing is working. In a lot of the models, the expectations are set from the historical revenue base. So if you look at Maryland and Pennsylvania they worked on creating targets for avoidable utilization and that range 3% in Maryland to about 5% in Pennsylvania. So there is a lot of analytical work to look at this concept of avoidable utilization and how much reasonably we can reduce it over time. There are some studies on the care coordination and we see 30% reductions given the population that they targeted. But my experience with those studies are they really narrow it to a very high cost patients and then they show big gains like 30% over one or two years which when you apply it to the population level reduces the impact and reduces the numbers. So I'm happy to kind of take this offline and provide you a little bit of detail on the evaluation studies with that, if that will help. And then one final question, this might be totally mixing apples and oranges but as you know, last year, CMS required this price transparency information to be published by hospitals. And I think everyone here on the ground who's looked at it says it's a mess. You know, it's just, you can't compare apples to oranges apples to apples across hospitals. People have defined the coding that they've used differently, they've used different formats of presentation and so it's really not useful. But on the other hand, it could be useful. And I'm just wondering whether you folks have crossed paths with that and have some thoughts about, gee, you know, if this were just better organized or on a template that all hospitals would use there's valuable information here that would help us see into the realities of pricing across different providers. Tom, yeah, I think that reminded me when the EHR's electronic health medical records were rolled out to do the CMS, there were no standardization and we are after, I guess it's also with the ACA over 10 years, now we are trying to figure out how to standardize and use that data better, right? Transparency is another area where we could have impact if people have better knowledge of the prices that they're gonna pay, both the patient but also the purchasers, right? So comparative information. We've been thinking about that a lot actually at Mathematica, the initial reports are gonna be probably useful for people like me and like you who could understand the details and make sense of it, it's not gonna be useful for the patients unfortunately yet, but it is the first step in my view that now we are gonna have this data coming in and collectively we have to work with federal government and the providers to make it more useful. I agree with you currently, we were questioning, okay, what is this gonna show? And with all the experience we have collectively at Mathematica, we were puzzled in terms of like making sense of even the data that we got for our own hospitals. So there's a lot of work to be done there, but I think that that's a valuable, like you said, to get a better sense of what the prices are in the hospital sector. Thank you. Thanks, Tom. Next we'll go to Robin. Thank you. Thank you, Shulei. That was really interesting. And I especially liked your clarifications around that this type of a dashboard is really the way I would say it which might be a little bit different than the way you said it is that it's measuring potentially avoidable care at what we would call the HSA level. So really looking at the community level and it's not all obviously on the hospital to fix that that would have to be a joint effort of the community as a whole. So I liked that perspective because I think it aligns well with Vermont's history and the blueprint in our efforts in healthcare reform in general. I was wondering if you had any plans or thoughts about including commercial data at some point using APCDs in the dashboard. Robin, I'd love to do that. I think for a specific state, we were able to do that in Pennsylvania and to a certain extent Maryland has been working on that as well. So we could do that with your APCD, right?  Other pieces like try to benchmark and try to see, we don't expect them to be zero, right? So the other piece about this is, we'll never get to zero. That's not the goal. But what is the reasonable level that we could target that will require commercial claims. And we are kind of thinking about whether we could use commercial claims databases to create a commercial component as well as using the Medicaid claims that we have access to currently and add those two payers into our dashboards. Yeah, yeah. Because from the other thing that we didn't discuss is value-based purchasing for providers to invest. So reducing this is gonna require investment. And if you do it payer by payer, and this is my all payer, I guess my all payer slant and preference, what we observe is if you do it payer by payer, you are not creating enough incentive for hospitals providers to make major investments, right? So the more we could think about from an all payer or multi payer perspective, the stronger incentives would be and the alignment will be there as well if you are using the same concepts and same definitions. Thank you. I didn't have any other questions. Thanks very much for the presentation. Thank you, Rob. And next we're gonna go to Jessica, Jess. Great, thanks. And thanks, Shuley. This is really helpful. And I think it's gonna inform some of the work that we're doing around hospital sustainability and preparedness for value-based payment, which I'm gathering from what you said in the presentation, value-based payments are coming. That's really not debatable. I mean, coming in a comprehensive way, that'd be the primary form of payment. I guess it's not really debatable what maybe is debatable or what we have to think about is are our hospitals and our providers prepared for that transition? And so this is really helpful in that regard. So I'm wondering if you've done research or Mathematica's done research into what are the factors that are really the biggest drivers contributing to avoidable utilization, whether it's lack of primary care access or lack of access to the wraparound services and community support systems, or is it ineffective care management, or is it poor discharge care plans, poor follow-up? In some ways, I'm wondering what are the big drivers because then that would help us figure out what factors could be addressed, what would have the biggest impact on reducing avoidable utilization if we understood what are the biggest drivers? Yeah, it's a great question. I think there are some studies in terms of like looking at readmissions, what factors impact lower readmissions than how providers implemented certain interventions, right? But from like we've been working a little bit looking at the associations between certain population health indicators if you have a higher prevalence of certain conditions, does that have impact on the avoidable utilization? So we are trying to look at it from the area level perspective to see associations to help with that decision. There is a vast literature on the readmissions and avoidable utilization on impact, but I don't think I haven't read any article or any study addressing exactly what you are, like comparatively, right? Like comparatively where it needs to focus. Yep. Got it. And actually with respect to the readmissions, I know you pointed out that the measure that you used was readmissions only to the original hospital. And I understand that because your audience is the hospital itself in terms of their financing and preparedness or value-based payment. But in some sense then that actually means that this is probably an underestimate of truly avoidable utilization because there could be readmissions to other hospitals that could have been avoided that aren't captured in your data. So at the very least this is, you know, probably an underestimate. Definitely. Definitely. Definitely. Yeah. Especially if you think about rural hospitals, right? You know, a lot of the readmissions could be happening to other centers not coming back to the originating hospital. And in general, we had done some cities when I was in Maryland, 50% in general, like average, 50% of readmissions are happening back to the hospital and 50% is going to another hospital in Maryland. So if you run this algorithm, you know, we could measure those as well to measure the overall avoidable utilization. Right, which would be really helpful to understand. Yeah. And then you broke down the categories of avoidable ED visits. And if I'm remembering correctly, it was like non-emergent, primary care, treatable, and then emergent, but could have been prevented, right? And I'm wondering if any of the work that's done here breaks it down by those categories by hospital because to some degree, understanding, you know, whether this is, what percentage of the avoidable ED is non-emergent might have a different solution than emergent but preventable. Or, you know, I mean, I'm just thinking that it actually might matter what the breakdown is. Yep, yep. Is that something easy to do or has been done or is easily pulled out of the data? It could be pulled from the data. What we did with the Pennsylvania hospitals once we created these reports, first they were shocked. With that 30% on the Medicare side, they just kind of, it took a while for them to believe in that number. And once we did that, then we provided detailed reports and break it down into those three categories as well as giving them some diagnosis information for them to really focus on what kind of conditions, like detailed conditions are drawing the avoidable utilization to ED. And they took that reports and they are working to create some interventions, working with their ED. They put the care coordinators in their EDs to start addressing some of those individual diagnoses or conditions that they've seen in the data.  And I recognize Pennsylvania is different than Vermont. But I'm just wondering, is it more than non-emergent or is it more the emergent but preventable? I need to go back, sorry. I don't have that in my head. Yeah, no worries, understandable. I just was curious. And then I guess my last question is, when you look at the data for Vermont, and I guess I can go back and look on this pretty comprehensive website. But I'm just wondering your first pass at it, looking at how does Vermont compare to other similar states? Where do you think we are? I mean, it's similar. I didn't see Vermont as an outlier. So I think the ranges are similar. You see some variation in the hospital. So it is really difficult to do a comparison, right? Because your denominators are different type of hospitals you have. So if you're interested in that type of analysis, then we may wanna control certain things to see where we're not compared to other states, right? So it's really hard judge in a way, whether you have a high or not, yeah. Okay, I was wondering if it jumped out of you in any direction. No, no. It sounds like we're right in there with the masses. Okay, those are my questions, Julie, and this has really, really been helpful. Thank you so very much. Thank you. One thing to add, we did historical analysis in the past. It's like in the past 17, 18, 19, they are stable. So those trends are not jumping up and down, which is interesting to me to think about that nothing really changed in the last three years. Do you mean that nationally or do you mean that for Vermont? We didn't run this historically, so maybe that's another one. In the other data that I've seen in Maryland and in Pennsylvania, we'd run historical data and percents were similar until of course Maryland started their program. So then things started changing a little bit. Great, thank you. Thanks, Jess. Julie, on slide eight, you have the list of the conditions, and I'm just wondering in your research if you did any rank ordering by frequency or costs so that there's some type of order to what is costing the system the most in these conditions that can be avoidable? Yeah, we didn't look at that one. That's another good one. So I'm taking notes on in terms of our next iteration of the dashboard to add a little bit more detail. What I can tell is like from our work, U2Is, urinary attract infections are kind of the low hanging fruit, so to speak, that the provider seeing a quick, good interventions can prevent U2Is much more so than some of the other like diabetes or COPD. But we didn't run that with the national data to see what that order is. Okay, thank you, Julie. At this point, unless there's a board member that has additional questions, I'm gonna open it up to the public. Does any board member have any additional questions? Hearing none, I'm gonna open it up to the public for public comment or questions and please address anything through me. And I'm going to start with Jeff Thiemann. Thank you, Mr. Chairman. Good afternoon. And thank you for the presentation, Shule. Really, really good work and interesting. As board members said though, there's a lot to digest here and I think we're just seeing the slides and hearing your remarks about them. So for the board's purposes, Kevin, we may submit a letter responding to some of what we heard and trying to further contextualize a little bit of what Shule had to say. So that may be coming. I do wanna make a couple of quick comments, I think, though, since this presentation and topic is focused on utilization. And I think given where we are in the pandemic, it's really important at the moment to take at least a second to look at utilization through a current today lens. And one note on readmissions before I do that is that I think it's important to recognize that there are a lot of factors outside providers control, outside the hospitals control that dictate whether someone is readmitted and that can include whether they follow a care plan and are adhering to discharge instructions and all of those kinds of things. So that's just some of the context we may provide. But when we get back to utilization through a current lens, what I can tell you is that right now Vermont's hospitals are very busy, they're very full. There's a lot of volume and utilization right now. They're busy in the emergency department. They're busy in medical surgical wards and psych units, outpatient clinics and surgical sites. You name it, people are coming back to the hospital. This represents, to some extent at least, if not to a large extent, care that was delayed or deferred during the pandemic for various reasons. And it is filling up our hospital beds and in the mental health space, having patients who really need care, seeking that care in the emergency room, often with few options for where we can properly place those people for the treatment they need and deserve. So that volume only continues to intensify. And I think you're seeing that in headlines, not just here in Vermont, but across the country. And then when you combine those factors with our ongoing workforce shortage and the challenge we face there, and which adds to our daily costs on a kind of rapidly increasing basis, it just sort of fuels the notion that hospitals are doing a lot more with a lot less as the uncertainty only grows. And couldn't agree more with Shule that at the same time, we continue to make the right steps and be a trailblazer in Vermont towards moving to the value-based payments. We all know the system, you know, probably would function better with if we could do it on a broader basis. So I think in the upcoming budget hearings, you will hear a lot more detail about the utilization issues I just described, probably some responses to the slides that Shule shared. And also, you know, we'll gain a fuller appreciation, I think, for some of what's going on right now. But we may follow up with additional comments. And until then, Shule, thank you for your work and presentation. And thank you, Mr. Chairman. Thank you, Jeff. Next, I'll call on Ham Davis. Thank you, Kevin. I don't know if you could ask for your consultant question. I'd just like to read, just like to know whether in her work, whether you get a metric like either readmission to the hospital or, and I totally agree with Jessica, that the much more important is the revision surgery. It's certainly in Vermont, which happens all the time. I'm just curious whether the public knows anything about that in Pennsylvania or Maryland. And let's say that you have, did they publish hospital data about revision surgery, about readmission to the hospital? So basically, Shule, Ham has asked whether or not there's any public transparency on readmissions. Yeah, great question. I think we talked about the price transparency and the quality transparency has been a focus as well. As you may know, CMS publishes the readmission rates in their website for the Medicare population. And in Maryland, they also publish complication rates. So this is the complications happening during the surgery or during the visit as well as rate mission rates. I think public transparency is a complicated and a different perspective. So you really need to work hard to make them understand what it is. And a lot of the payment policy work is happening at the regulatory level and it's not their primary goals. So I think there is a lot of work to be done to take some of this work and create the transparency for the patients to understand what they are receiving. And at the end of the day, Maryland did a focus group with the patients back in the day when we were trying to prepare for the second phase. And patients as well as the providers at the hospital, they didn't connect, they didn't know about this payment, whether you are paid on a fixed revenue or a fee for service, what they knew what was changing for them, right? So we kind of have to have that lens as we're looking at this data and do more public reporting in a targeted and a different way. So what I presented to you as I mentioned, the audience is really hospital executives and the policy makers. It is not intended for patients to use. Can I have one more question, Kevin? Sure, go ahead, Ham. I'm curious about, one of the things I'm curious about that really has never been a major factor in Vermont, but certainly could be, which is the whole idea of global hospital budgets.  Would global budgets, if we had global budgets, do you think it's any kind of a problem that you could take a hospital that just can't really function as a full service hospital in any effective way? Would a hospital, would a global budget get in the way of a natural solution to that problem? So Ham, I think what your question is, and correct me before I pass it over to Shule if I've got it completely wrong, but is there something inherent in going to global budgets that would not create the same type of fix as for example, if a hospital wasn't doing things properly, I think what your natural fix is a closure, is that correct?  Same thing at Fannie Allen in Chittenden County, same thing at Curbs Memorial in St. Alvin, same thing at Barrie City in Barrie, and so my question is, you know, my question is- And Proctor. I'm sorry. And also Proctor, that was six years ago. But I believe you that the question is, the question is that, the question is whether, you know, what to do about hospitals that are very marginal. We've got one in Springfield out there that has just emerged from bankruptcy and Fletcher Allen and UBM rescued Porter from bankruptcy. So the question is whether, the question is whether global budgets would change all of that kind of dynamic altogether. Julie, you want to try to take a stab at that? Oh, I will, but yeah, that's great question again. How to protect this, right? First of all, global budget is not a silver bullet, right? So it's not going to fix the problem of what kind of services our communities need. And the hospital acute bed concept comes from a, 100 years of the, you know, the population needs that originally we need acute beds and we needed to be treated at the hospital. That's no longer the case given where we are in our life expectancy and the burden, right? So it's all about the chronic conditions and management. To me, you know, you may call the hospital closure a solution. What is left behind is the problem most likely, right? So global budgets could give you a glide path to transform the hospitals in the community to whatever they need. And whatever need is still to be determined and I don't see a lot of work. There I think American Hospital Association published something recently about essential and you guys are working on that as well, essential health services. The finance is a small puzzle. I think the bigger problem is the delivery reform. What kind of infrastructure we need in the rural communities and how we can get there. Global budgets fixes one small problem that they don't need to chase after admissions and EVs to keep their bed open, their doors open. And I think prior comment mentioned COVID and I think that was a little bit of a wake up call for a lot of people nationally about sustainability. You've been thinking about this all along but others didn't pay a lot of attention about the capacity and creating sustainable health system. If you let these hospitals close abruptly, especially then we are gonna be kind of dealing with the problems rather than solution of the problem of the rural hospitals. And one thing, one else to add. Yes, there are some individual issues with the management but you saw that national charge, right? So 108 rural hospitals are closing. That tells me a systemic problem rather than a individual management problem. So I think we really have to think about it from the system perspective and the population health and what we need. I hope that kind of starts scratching some of the answers and maybe we can discuss more if needed. Thank you very much for that. And I appreciate my question I think was badly framed. I think that you do not have to necessarily just close a hospital. You could shift its focus from a full service hospital with surgical lines with very low volumes, therefore very high unit costs and then a quality question coming out of that. So the question, what I meant my question to be was what the hospital needed to be a clinic of some dimension rather than a full service hospital. But you don't have to go in there, Kevin, I got it. That was very helpful for me, thank you. Yeah, one more thing to add. Sorry, Kevin, if I can, right. I think that's the problem, right? The fixed cost in the hospital and traditionally our payment system provides more resources if they keep their inpatient beds open, right? And until we solve that problem, we won't be able to transform them into whatever we want them to be. To me, global budget could give that revenue stream and help them to glide back to that next stage. The important thing is what are they gonna do, right? We know what the challenges are. The question is if you were to give them fixed revenue, what would you expect them to do and what kind of services you would kind of collectively think about hospitals providing in their communities? Yeah, I think the point that Ham's trying to make was the question, thank you. Yeah, and just to follow up, Pam, I take your point to be and you can tell me if I'm taking it wrong, but I take your point very seriously because what I hear you saying and what I agree with, but maybe you're not really saying this and I just want you to say it, is that if you were to move towards global capitation that the first discussion is where the hard decisions are being made because you're determining what is the right care at that institution. So. That's exactly right. Ma'am, you can just answer Kevin's question. That's my question. I think she already has him. So. I'm completely happy with it, Kevin. Thank you. You get coffee, Kevin, at real time. Thanks. So I did see a hand raised earlier, but it's been lowered. Mike Deltrack, did you have a question or has it been answered or? I'm all set. It's been addressed. Thank you. Thank you so much, Mike. Any other member of the public who wishes to offer public comment? I'm not seeing any hands raised, but if anybody's joining us by phone, if you would just speak up, that would be fine. So hearing none. Shule, you sparked a lot of good conversation and a lot to digest. We look forward to hearing back from our hospitals on the conversation that was started today. And thank you so much. We know that you're very busy and we appreciate the amount of time that you've put into this. So thank you so much. Thank you so much. It was my pleasure. And I'm looking forward to what you guys are gonna come up with and work through these. And I'm happy to help any way I can. Thank you, Shule. So next item on the agenda, is there any old business to come before the board? Hearing none, is there any new business to come before the board? Hearing none, is there a motion to adjourn? So moved. Second. It's been moved and seconded to adjourn. All those in favor, please signify by saying aye. Aye. Aye. Those opposed, signify by saying nay. Thank you everyone and have a great rest of the day.


Hello everybody, E here. Welcome back to another book tag video. I haven't done one of these in forever. Last time I did it, we were over at the desk. And I think it was JB's book tag. I've done a book tag since then. I created one called the Author Playlist. Thank you to everyone who did that. I haven't watched all of your videos yet. I think I still need to watch Jen. Jen Bernardini. But I am super behind on my videos. If, well, I shouldn't say if you're wondering where I've been because I posted numerous videos. I had 22 videos to upload when my internet went out last week. I had problems with AT&T. None of the satellite services said they could guarantee service out here, which is unheard of. Even on Twitter they're like, it's funny because my friend H. Michael Casper said, hey, where do you live, the moon? And one of the, I think it was either Viasat or Xfinity said you might as well be living on the moon, which I thought was hilarious. But now, I think it's hilarious. I didn't think it was hilarious at the time. But my internet went out. It was about a week. I was gone. So when you didn't see those videos, it's literally because I couldn't upload anything. But I was still filming. So I still have, I think I have about 10 more videos to go up. I know I bombarded you guys, but I said all that to say this. This is the first new video. The video's coming up after this except for the Tim Mayer unboxing. All those videos are still old. I apologize for uploading so much old content, but it's all done. And I thought I was going to be able to do like two uploads a day, two uploads a day for like, you know, three weeks. Or no, for, if it was two uploads a day it'd been two, whatever. I'm not good at math. Math, math, math, bad, math, make, eat, angry. Anyways, but thanks so much to Regina, Regina's haunted library for tagging me in this. This is originally created by Jason's Weird Reads. I'm a fan of both of their channels. Links will be down in the doobly-doo. Let's go ahead and jump in this. All right. So the tag is the book snob book tag. And we are going to start with number one, of course, the adaptation snob. Do you always read the book before you see the movie? If we're going to make up percentages, I would say about 95% of the time. Yes, books where I have absolutely no interest in the book, but I do want to see what all the fuss is about.  I have no interest in most of those things because they're either YA or middle grade or whatever. So I just have no interest in them. And we'll get into that more later on in this tag. But I have no interest in them, so I'd prefer to watch the movies. And is it different than the books? Of course, it is. I've eventually gone back and read the Harry Potter series. And I actually prefer the movies just because it's not such a long experience. But that's just me. But usually, especially with Stephen King or Joe Hill or Caroline Kepnes or any of my big fandoms, I will definitely watch the movie second to the book. So I'll read the book before. Like right now, I'm reading Through the Goldfinch by Donna Tartt because the movie adaptation is coming out. If you want to start buddy, when this goes up, I'm at page 70. If you'd like to jump in on the read, go ahead. It's whatever. It's me and my friend, so many people. It's not Aaron. Who is it? Richard. Me and my friend Richard are reading it together. And I think my friend Tim might be jumping in. I don't know. But if you want to get on that, just let me know down there in the doobly-doo. All right. Number two is Format Snob. This is easy. You can only choose one format in which to read books for the rest of your life. Which one do you choose? Physical books, e-books or audiobooks? I'm going to say controversial opinion here because I have a feeling that at some point in my life, if anything is going to go, it's going to be my site. So I would go with audiobooks just to make sure, because I have great here. I have great site too. But I have diabetes in the family. I've been diabetic. I'm no longer diabetic. So my eyesight is probably going to go first. I just feel like audiobooks would be the thing. But if we're talking about actually reading, like words on a screen, I have to go with hard covers because usually the type, nowadays the type is of a good size. I don't like paperbacks. They're too flimsy for my liking. I destroy a paperback while reading. And hard covers stand up to the punishment that I give them. So I'm going to go with audiobooks with the caveat, hard cover. Okay? I'll discuss that down there. Ship snob. I have no idea why this is called a ship snob. I guess relationship, is that it? That's that's what I'm taking from this. I know when you ship two things, like I thought it was going to be, you know, who do I ship in like the books community or something? This number? I don't know. But would you date or marry a non-reader? Absolutely not. I am that much of a snob when it comes to this kind of thing. I have nothing in common with a non-reader. My entire life, I've been a reader. And if if I can't talk to someone about books, if they're just going to zone out and blank out and like, why do you even care about the words on the page? Then I don't I don't want to be with that person. Shell, however, reads the this is kind of like Regina was talking about in her video. My wife reads the exact opposite of what I read. She basically reads everything except for romance that I don't read.  She teaches our kids. We're secular homeschool and not religious homeschool. So she constantly going out and educating herself. That sounds like I'm saying, well, I mean, it's true, but I'm sorry. No, I'm not. But the so she's constantly trying to educate herself so she can give the kids the newest information. And my nonfiction stuff is usually pop culture or celebrity, you know, that kind of thing. Sometimes it's politics where she is all about science and mathematics and all that all that stuff. So she's constantly educating herself. Whereas for my my dollar, I want to be entertained. So because that's still my escape. Now, my screen flipped a genre snob. You have to ditch one genre never to be read again for the rest of your life. Which one do you ditch? I think it's going to be romance. Just like with Regina said in her video. Romance just does nothing for me. And I think the reason for that and I've said this before in earlier videos, there is no greater love story than the one that I'm living now. I've tried reading romance and I was like, I just don't get it. That's either I look at I read those books and I'm like either that's not love or you know, that's like lust or over here that's that's, you know, abusive or that's this that and the other way. I have never read a romance book. Of course, I've only read maybe two dozen in my life. Anywhere from Harlequin to contemporary, all that stuff. I have never read one of those books and been like that's better than what I'm experiencing.  Uber genre snob. You can only choose to read from one genre for the rest of your life. Which genre do you choose? I'm going to say literary fiction. That covers the gambit of everything I like to read. And there's there's pieces of every genre in that one. So I'm going to cheat and say literary fiction. But if I have to narrow it down to like the the main genres like horror, sci-fi, fantasy, romance, that kind of thing. The themed kind of thing. Literary horror. The bang for my buck. Or magical realism. I'm really bad at choosing between these two. It's like having to choose between a Stephen King book and a Heruki Murakami book. I don't think I could ever choose, you know, which one that I could... I need my Murakami and I need my King. You know, I need my Kepnis. I need that kind of thing. So as long as there's really, really fantastic writing, that's what I want to be reading. So and literary fiction is where it's at right now. It's basically where it's always been. That's why literary is in the name. But yeah, so literary fiction or if I need to narrow it down literary horror. These last two ones, we're going to get into a heated discussion here. I feel very strongly about both of these and it's funny because I might come off sounding hypocritical. So that's fine. I can be hypocritical and we can have discussion about it down there in doobly-doo. The first one is number six. I'm waiting for my phone to act right. Okay, there we go. Community snob. Which genre do you think receives the most snobbery from the bookish community?  That they are... that these... especially the ladies of the community are cardboard cutouts of one another. I understand where that... I understand where that mindset comes from. They all have the white bookshelves. They all have the rainbow colored book scheme as far... and that drives me nuts. It drives me nuts too, everybody. That agrees with me. It drives me nuts too because I'm a... I'm a... in order... I like... I library organize my fiction.  But nobody deserves hate. Nobody deserves hate. I get plenty of hate for, you know, whether it be, you know, my family, the opinions I have on the internet, the opinions I hold personally. I get a lot of hate and I expect it.  I expect hate. With the YA community, I got a lot of comments when I first started filming that really upset me. There was a... a lot of comments about, you're the only straight booktuber.  You're one of the only booktubers that are... that is a man. You're the only booktuber I watch because of that.  He's big enough that he could hire people to do that if he wanted to. And that's just my own opinion. But I am... I'm not that person. I am not the person that you... that you... that you think I am. If you think that I am a straight male booktuber. I don't... I don't fit into those categories because I don't believe in those categories. It's not something that I personally believe in it. But what I'm getting at is I got those comments a lot. I also got comments constantly about how I was the only male...  It's not true. You have Adam Cesar, you have Jason's Weird Reads, you have loads of Cameron Cheney, you have loads of men talking about adult books. Um... but at this... so with those comments, those made me feel uncomfortable also, and it also made me feel unwelcome, which is where the hypocrisy comes into play. Am I wanted in this community?  Um, you pull up everybody else's channels. Uh, I don't see one that looks like mine. Um, you may find it, and if you do, I'd love to see it because I've never found it. I'm not bragging about being original, it's just I... I don't fall into any categories, then I've... I've never tried to fall into any category. Um, but the... the hate that the YA community gets, if you don't like the books, don't read the books. Um, if you don't like the booktubers, don't watch those booktubers. I don't understand going out and actively searching for stuff that you hate. I don't get it. I don't understand the mindset.  Now, if we're talking about in general, in general, of course it's the romance community. No, everybody shits on the romance community.  No, there's no... there's very few people out there celebrating Twilight and Fifty Shades of Grey. But there's plenty of people out there celebrating horror novels based on vamp... vampirism and, you know, BDSM. There's plenty of celebration going on there. You don't see any, but you see people making fun of that. And the, you know, the, what is it, the, not the buttress, the bosom... What's the, the, whatever, the, I can't, I can't even think of the name of it, but the, uh, I'll think about it. The Harley Quinn covers and everything with the women with the bulging chest meat and the dudes with the bulging chest meat and everybody's got bulging chest meat.  I have good friends who read that stuff, um, and they're constantly getting hate. Nowhere near as much hate as I get for reading horror.  It seems like it's okay to make fun of romance people, um, and I don't, I don't like that either for the same reason.  Yes, we're fat.   Like, no, no we won't. If you, if you love eating, you're going to continue to eat, and if you love romance, you're going to continue to love romance. Not, no amount of hate is going to change that. Now, for the last one, snobbery recipient, have you ever been snubbed for something that you have been reading or for reading in general? Um, yeah, of course. I mean, the, one of the books on my top 20 list of all time is James Newman's animosity. You get a lot of sketchy reactions when you say that you're a horror fan.  Um, but throughout my whole life, I've always been judged to be the bad guy, and this goes into why I don't really care too much what people say about me or how they feel about me or what they, what what they say, period. I'm very protective over certain things, and of course I'm not going to tell you because that'll give fuel to the trolls, but um, there's certain things that will push my buttons, um, but it's, it's never been people judging me for what I like, if that makes any sense.  You know, it, do you see the same, I think you see the same kind for every, for just about every genre, for fantasy, sci-fi, horror, just about any genre, so I don't think that there is one that, that, you know, that I have, I think if anything it'd be horror, but it's never affected me, I guess is where I'm going with this tirade. Um, I just feel like, you know, there's never been significant hate pointed in my direction for liking something. Now, with that being said, there has been significant hate shoved at me because I dislike things. Um, uh, the Mailerman fans, the Tremblay fans, uh, I just recently had a discussion with, uh, someone over, uh, the blog posts I wrote, that were here where I mentioned Tremblay, um, in a, in a joking manner, and they took offense to it, and I'm like, I, I can't help that you're offended, I mean, because it was supposed to be offensive, that humor was offensive, um, but I get more hate from people who can't accept the fact that I don't like what they like. In fact, I just got, I got three comments last night after I watched Regina's video, I got three comments that said something to the fact that I don't understand why you don't like this, this book is the greatest book of all time. One of them was on Tony Knocker's, uh, I think the other two, I can't remember.  I'm sure of it. So, where's all the hate coming from? I don't, I don't get it, you know, I don't, I don't eat it jack-in-the-box, well I don't have jack-in-the-box, but I don't eat it jack-in-the-box because I don't like their hamburgers. When I lived out West, I didn't eat there because I didn't like their hamburgers. I prefer Burger King or McDonald's. I'm sure there's plenty of people who love jack-in-the-box.  I don't understand it. Why do people do it? If you're the type of person that has ever commented on someone's opinion, saying, I don't understand why you like, I want you to explain to me, and you're probably not watching this video because if you don't like opposing opinions, you're not a fan of this channel. I know that already. But I want to hear from those people. So maybe tag some of your, give them the time code for this video. I'd love to talk to you. I would love to, what, what exactly do you hope to accomplish? It's like, it's going back to what I said earlier about fat people and romance fans and whatnot, and equating those two things.  What exactly are you trying to accomplish? I don't get it. I don't understand that mindset. I never have understood that mindset. So I would love to talk to somebody who has that mindset, who is not a complete another douchebag, because usually those kind of, those kind of debates or talking points usually devolve and, you know, just rot from, from, from the outside in until it's just a smolering dumpster fire of just fuckery. But anyways, thank you so much. I went off on a tangent.  So I'm not going to tag anybody, but if you want to do this book tag, please do, please give credit to Regina for tagging me, and especially Jason's weird reads for his video. I believe he created it, from what I understand he's the one who created the tags, and definitely check out their channels. They're down there in the doobly-doo, but until next time, I have been E, you have been U, this has been the book tag video. Ooh, I can't wait for the comments. I'll talk to you guys later. Bye bye!


boom What's up when the gigs mr. V here welcome to another video so and this one we are going to talk about ticket symbol psfe Paysafe This is one of these online payment system that we cover here on the channel when they went public And I told you guys that this is a company that I think has a future Because of the direction that we're going with eye gaming online gambling And e-commerce so I thought this would be uh from a fintech standpoint This would be an excellent play. So the company just released their earnings and presented us with Huge opportunities. So I'm going to talk about that in today's video But before we get started guys, if you're new to the channel We took about how to earn money how to save money how to invest and bail wealth So that's something that interests you go ahead and hit that subscribe button and the notification bell So you don't miss out on new content. So when it comes to paysafe Again, this is one that we covered in depth. So if you didn't watch that video I'm going to hook it up here. So you can definitely go check it out I gave you guys inside of the the business actually went through the investor presentation Why I thought it had a future So um this you know past week the earnings of the company came out and the company took a massive bidding And you know fully aware that um when companies take a bidding like this Sometimes it's a great opportunity for you to get in Most people see a company take a bidding they run away I supposed to being a bottom feeder and buying the dips on stuff like this. So earnings are usually Up and down. So if they miss one number Sometimes investors overreact and in this case again, I think it was an overreaction So again, we're just going to switch here take a look at just the company itself Again, if you want to learn more about their business model and some of the stuff that they do Go to the website. I'm going to put it in the description You can go read about it again or you can go watch the video that I did earlier I talked about what the company really does One of the key areas that I like about their business model is this eye gaming space Which is uh becoming more and more Uh mainstream more people are starting to like or get into this space It used to be gaming was so like, you know lazy kids that want to sleep in their parents basement all day And just play games and and don't want to do anything Today gaming is becoming more of an esports where people make a living playing video games I mean like there's one kid that actually earned eight million dollars from playing video games So you don't want to just look at like it used to be it's things of change. It's not a massive business And uh pay safe actually helps with the kind of payments that occur in that space where you let's say if you're playing a game You want to buy maybe extra power you want to send money to your friend So there's different things that you can do in that space. So that's what pay safe does again Go read about uh the company and their investor presentation. So, um, we'll jump right here I'm going to show you guys here. So this is what happened when the earnings came out So prior to the earnings this tag was sitting somewhere about seven dollars and 50 cents And then the earnings came out, which we're going to take a look here shortly and look at what happened It just completely crumbled it went from 750 down to 401 and again, I think this is an overreaction Because um the company one of their one of their main source of income Actually didn't see any growth which Again, like for a company that's up and coming that is developing new products and is trying to get into this space I think this should be just up and down. So as a fact investors were not happy They actually You start took a massive beating. So Take a look here. This is for market watch again pay safe You know collapse just because of that because the results didn't meet what they wanted So you can go there. You can take a look and see how they miss but they are on their A presentation here. So the digital wallet that is the one area where they actually struggled the most So you can see here. No investor wants to see this thing trending down You want to see a trending up not trending down? So you're going from 395 For the digital wallet down to 355. So you're trending the wrong way And investors don't like that. So again on the call, they talked about ways that they want to improve this And really work on improving this digital wallet. So but their eye gaming Area it grew pretty well. Their e-cash grew pretty well. So again anticipate about 18% in the e-cash business 18% growth year over year. So this is a positive sign. So my personal take I think that people over reacted to this particular You know earnings even again As an investor you look for these opportunities. You see not only they did not meet expectations as far as This particular digital wallet performance, but they have a game plan to take it to the next level They have a game plan. So they have two main factors. They talked about internal factors, which is bringing in the skill set that they require and the right personnel to lead the digital wallet space and then also external factors like You know rules and regulations out in europe, which you definitely impact your business. So Something that they are working on. So i'm not too scared about this. This is not stuff that may make me pull As a matter of fact, these actually give me an excellent buying opportunity Like I said, if you go from here to down here, or if you're not in the start yet I think this would be a great spot for you to open a position Because you're really buying this thing at a discount like massive discount because I think it's nice if we can go back here maybe about That far back if you can see this thing went to a high of 19 dollars and 50 cents And this was back in january of 2021 and so look at where we're sitting today ever since that high it's been trending down which um actually It's not a good sign But now for if you're looking to get in again guys, this would be one that you can get in Mostly for a swing opportunity because normally after a massive collapse like this You would see a squeeze to the upside so for a swing opportunity If you can buy this and hold it even if it gets back to six dollars You are going to be sitting pretty good. So that's my game point. So what I did here again with after this This particular earnings what I did is um when you drop down to that 40 I think four dollars and 20 cents actually but um Some costs there, but I think like seven dollars or eight dollar calls I have to go double check that but I bought those calls in anticipation for that bounce And then also I actually bought a thousand shares Just to go long on those and so I can use those Thousand shares to do cover costs which can generate me Extra income why I'm holding the the share. So that's my strategy there. So again What should you do if you have pay safe? If you can afford it, I would say average down Again dollar cost average down and if you if you got in at that seven or eight dollar price point Then find a way to average your way down If you're not in there, I would say now it's the best time for you to open the position And start looking for an opportunity To actually keep adding as these things to the squeeze back if you're just swing trading Yeah, and then you can either go two ways you can do the the calls or you can actually buy the shares outright If you can afford them. So that would be a plan that you can actually implement. So What happened it pay safe earnings came out Missed their earnings Wall Street didn't like it. And so our price of the stock totally collapsed and again The specific area in the business that took this this massive bidding and I I call it massive bidding because all the all the areas in the business didn't Didn't do that bad But their digital wallet took like a bidding and they didn't like that. So but again, we are Missing earnings like this presents a buying opportunity for you if you are looking long term So definitely find a way if you haven't already This would be one that you can swing or you can get in to write it long term Let me know in the comment section what you think if you currently have the stock in your portfolio What's your game plan?  Again, let me know what you think if you're new here We talk about how to earn money how to save money how to invest and build wealth So there's something that interests you go ahead and hit that subscribe button and the notification bell to don't miss out on your content also guys if you're looking to get started with investing I think mumu has the best Promotion right now if you sign up and deposit any amount one dollar two dollar You get five free stocks somewhere between nine and three thousand five hundred dollars And you can put the links in the description below and as always guys Do your due diligence.


Kotor has finally played Sonic Mania and it's left him with complex feelings that he needs to express. We don't normally do reviews, so we thought we'd tell you a story instead. This is what it feels like for a lifelong Sega fan to play Sonic Mania.  It was the boy's fifth birthday. He hadn't asked for any present in particular, but he received a best friend for years to come. The boy and his hedgehog did everything together. Over many long, wonderful summers, they would play together in the bright sunlight, running about with glee. When the boy went to school, his playground adventures were filled with the exploits of his hedgehog, as he and his friends acted out the events of their favorite games. They'd compare notes each Monday on the cartoons they'd seen that week, and come up with their own new stories starring their hero. The boy's very first regular comic book series was all about this speedy blue friend, and it would inspire him to go on to try and become a comic artist himself one day. He would draw blue hedgehogs and two-tailed foxes on every piece of paper he could get his hands on, trying to perfectly capture his friend's playful smirk. But nothing lasts forever. One day, as the boy continued to grow older, his little blue friend waved goodbye. In his place appeared someone new, who seemed somehow edgier, more adult, whose games felt very, very different. The boy was confused. Was this the same friend he'd known for years? He looked similar, but not the same. This new hedgehog seemed far more fascinated with guns and swords and werewolves. There was some fun to be had here, maybe, but it just didn't feel right. Something was missing. The boy tried his best to like this new hedgehog, but he just couldn't quite convince himself that he was having fun. His new friend had a habit of dragging the boy off on adventures that seemed like a fun idea at first, but quickly became uncomfortable, frustrating, and tiring. Maybe the boy was just getting older. Maybe it was his fault for being too wrapped up in the past and being unable to embrace the fact that nothing lasts forever and that you can never go back to your childhood. Even so, the boy thought, perhaps it was time to part ways with his friend. Things just weren't the same, and he had other important things to do. And yet, even as the boy grew older still, he couldn't stop thinking about the original blue hedgehog that he'd befriended all those years ago. No matter how dated his childhood adventures became, they never really lost their sense of joy. The boy never went very long without thinking about his long lost friend. He'd play his old games, sometimes reread the comics of his youth, and constantly daydream about what it would be like if a friendly little blue hedgehog were to one day return. Then, finally, it happened. The boy could feel it in the wind, something familiar had blown back into town. His arms tingled with goosebumps as he felt the joy and wonder and excitement of his youth bubbling back to the surface. Someone, somewhere, was calling his name. The boy ran, slowly at first, then at full sprint, launching himself off into the horizon to the fields where he'd played as a child. He could barely contain his excitement and he bounded across the grass in search of his lost friend. And there he was, a small blue hedgehog, as short and round, as bright and friendly as he had ever been, waving eagerly to the boy, beckoning him to come on one more adventure, another spin around playgrounds both old and new. With unbridled glee, the boy threw his arms around his friend. Finally, they were back together again. Finally, they were reunited. As the two sank into a warm embrace, the boy could barely hold in his tears. I never stopped believing in you, he whispered. Thank you for coming home. And so, hand in hand, the pair began a journey together. They'd been apart for a long while, but none of that mattered now. Things were as they'd always been. A little boy and his very best friend were reunited at last. The moral of this story is simple. Never give up on your childhood. Even if it takes years and years and years, some things are definitely worth waiting for.


This year on World Heart Day, let's use our heart to beat the cardiovascular disease. As you all know, the cardiovascular disease is the leading cause of death globally. It has many causes from smoking, hypertension, diabetes to air pollution and some other great diseases. In this COVID-19 pandemic, cardiac patients are faced with a double-edged threat. Not only they are scared to come to the hospital, they are also at a very high risk of developing severe form of viral infection. So if you have any health condition like heart disease, heart failure, diabetes, hypertension, don't let this COVID-19 stop to visit your regular visits to your doctor or you can call on the emergency numbers. It's safe and medical professionals are there to help you out. We can all look after our hearts and take steps to prevent the cardiovascular disease by eating a healthy diet, say, no-toes, smoking, tobacco and take plenty of physical exercise and set an example to our children and loved ones. During these recent years, we have seen that the younger people are more affected with heart disease. They are presenting with heart attacks and strokes, more and more younger people. Because of the current lifestyle, they are going through there with a high level of stress, lack of sleep, smoking, bad lifestyle, leading them to very hard to hire, keeping them at a high risk for the cardiac diseases. So it's very important that we take care of our lifestyles. Let's on this special day of the World Heart Day, we focus on our heart health, take plenty of exercises and make our hearts strong. At this point of time, taking care of our heart is more important than anything else. Thank you.


The CAMV35S promoter is known to be active in both plants and bacteria. Even the stable model protein DS red accumulates at low levels in both bacteria and plants. However, the levels are too low to cause any harm to either the operator or the environment. Additionally, the amount of A tumor facions present during the process is minimal and no toxins are produced by the bacteria. Therefore, transient expression is considered safe from a bacterial handling perspective. This article was authored by Matias Nodler, Paul Wynman Reunis and Johannes Felix Bile.