ne now down to rural hospitals with Kurdilbaq's hospitals included minus 6% that's one of the reasons why we're seeing the losses we're seeing cost go up as this gentleman here explained we're seeing volumes come down based on some of the things that we talked about we're seeing price relative to cost coming down and so we're here where we are it's everything in column one in that transition framework operating efficiency we do everything 60-70% of our rural volume drives right by the front door of our hospital if we keep 5% of the points of that in our hospital to have them come back to our hospital either promoting our quality getting out being part of our community more engaging our community getting 5% that's a 15% increase in volume and remember those mini contribution margins that's a whole lot of mini contribution margins to cover losses getting paid better I can't tell you a Medicare cost report I haven't looked at where there's not $250 to $500,000 of pickup just because we're not submitting our cost report accurately and getting paid for what we do appropriately it's right down that whole line of things aligning with private care getting paid for wellness visits getting paid are we in a rural health clinic you know all of these things I haven't left Rob on a list of all the best practices that we pulled together it's eight pages so I probably don't want to get into that right now but there's all kinds of things that we can do around turning our own performance around Chairman Lippert Yes This isn't going to reach all the way so if you have like any other Thank you I think this is part of more of a comment than a question but I feel like it's a challenge to address and that is I think the communication we need to communicate about the changes the fundamental changes that have been discussed here today the fundamental changes moving from fee for service to value based payment and the imperative of that is not being fully communicated I believe to our communities and as you said to your boards of directors to legislators to policy makers in the legislature and some policy makers perhaps in the executive branch as well and I think until we have until we stop second guessing the direction that is being outlined we will not be able to fundamentally move forward in the way that is required after that what Vermont has is a longstanding suspicion a longstanding and deep suspicion of big and so one care becomes a target and set itself up as a target at times for hospitals taking over physician practices rather than rescuing physician practices we have all kinds of swirling dynamics at work here including the cream on care board isn't it big and why do we have it anyway and why do we have to pay all the money to have it so we are doing this also in a federal setting where we are under attack where our committee has had to spend a ridiculous amount of time trying to trying to forge protections for Vermonters to push back against the attacks on the Affordable Care Act rather than being able to work proactively so I think we need to recognize the deep challenge of communicating more effectively with all the different constituent and stakeholder groups involved in the challenge that we are here to talk about today and I think this has been a terrific conversation but I think we need to I found myself sitting here over and over oh I wish so and so were here maybe they are here maybe they are not here but I think this is a fundamental basic issue for us as we take on these challenges can I comment on that first of all I just want to say I could not agree more with every single thing that Chairman Lippert just said it is really critical that we figure out effective and clear ways to turn this really compelling work into English that people can understand because it does get deep in the policy weeds very quickly and it is complicated and when you start getting into the mechanics of an ACO and the financial operations you lose sight of the big picture which is part of what I was trying to paint I think we are getting better at it but we need to continue to get better Board Member Jessica Holmes and I have been talking about trying to create a one pager that literally puts this at like a fifth grade reading level very clear exactly what we are trying to accomplish and how it is going to work and what the promise really represents I also just wanted to comment very briefly on the notion of big I certainly understand that in Vermont it is scary to think of big corporations and that the health network seems to represent that just by way of comparison as it was mentioned earlier United Optum employs more physicians in this country than anyone else and there was a recent merger of two healthcare systems in the west Dignity Healthcare in California and Catholic Health Initiatives in Denver that system combined created a health system with $150 billion in revenue 57,000 employees 400 care sites across 12 states that's big and by comparison what we have in Vermont is really quite tiny and I only say that by way of saying also that size also brings economies of scale and helps to achieve a lot of the goals that we are achieving here again the goal is to create a healthcare system that works for providers Thank you all I have a question about urgent care centers that you can think of that would be helpful around that issue I'm sorry I'm Mario Cortez I'm a state representative also on the Health and Health Care Committee I think I think it's an observation a couple of years ago and it's going to go right at the heart of the urgent cares cannibalizing the emergency room as a reason for not doing urgent care I was at a rural hospital system in southwest Tennessee larger community about 30,000 people they all the fears, they had 16,000 ER visits all the fears around if we open up this urgent care it's going to cannibalize our emergency room our revenue is going to go down all the reasons they opened up the urgent care which is now seeing 9,000 patients a year and their ER blind only went down 4,000 so they picked up significant patients that were leaving the community so that's just one kind of lesson I think today with the high deductible health plans that we talked about 60, what was it? 65% of small businesses have high deductible health plans if our rural communities with hospitals aren't offering urgent care at a reduced price from the emergency room we miss the boat we have patients leaving driving right by the front door of our hospitals going 40 minutes to an urgent care 300 bucks out of pocket rather than paying $1,200 one of my recommendations is if a rural community with a hospital does not have urgent care they start to use the rural health clinic designation they open up as a walk in but they expand their hours and they really offer that service to the community I was just going to add to that first of all from the one care perspective we're agnostic under good care we welcome as participating providers in our network but I think the bigger issue is why to me it starts with are people going to the ER but they don't really need the services that an ER is set up to provide and one of the reports that we generate at one care is for our hospitals is emergency room visits that don't lead to admission because if that's a high number people come to the ER and they're not as sick as you might expect them to be to go to the ER a lot of times other things you can look at are they coming during the day or are they coming off hours a lot of times people show up at the ER because we don't have good primary care access and they know they're sick and they know they need to see the doctor but they can't be seen or the appointment is tomorrow morning or we can't see you until the end of the day and they go to the ER so while I'm fine with urgent care centers what we really need to do is make sure we have good primary care access so people can see their providers for their needs if they're really sick we'll always have a 24-7 ER if we're good at that then I think to Eric's point the question is are urgent care centers then filling an important needed role in between good primary care access and emergency room and if they are then we should want them to exist in areas that can support them and if they're not and we've done away with that need then we should take stock of that as well I should state that I do have a concern about the free standing not hospital based urgent care but the urgent care clinics that would not fall under the state oversight Good morning I'm Jill Bray going to CEO of Northwestern Medical Center and I want to actually comment on a couple things so when urgent care we actually do have urgent care in our community it's right next to our primary care so it is really cool our access to primary care is critical we've reduced our ED visits by 5,000 and we started about 30,000 so it's kind of a big chunk by having access to primary care and our urgent care is adjacent to our primary care so when they come in oftentimes they don't have primary care access and we can link them right up so it's really about developing a system of care where the right door they're getting into the right door or they're getting transferred to the right door so it's an integrated system the free standing urgent care center that was in our community you know it's really about providing an exceptional patient experience and if we're providing an integrated exceptional patient experience the outside of that system almost can become a non-issue and actually don't exist in our community anymore but the thing I want to really speak about was really on Representative Liffert I want to really mention how key your comment was and Jeff you played off from it but it really gets me excited to think about alignment alignment within our organization which we grapple with that because we're changing inside of our organization about that big blue age alignment across our organization I care the hospital association board that collective impact so we're doing things consistently across our communities to provide the best care ACO brings us together to do that so we're integrating and the other thing is what about this systemness is it about going into a larger corporate structure or really is it about designing across our community the accountable communities for health and do we create an umbrella so that we can consolidate administrative functions we've all got HRs and we've all got IT make all these things so we think about merging into bigger or do we integrate across our community because that's where the capitated system aligns with where is the patient primary care is in home health long-term care is in public health mental health across our community that is amazing alignment that's happening across our communities and if we can align the political good and the regulatory good that allows us the flexibility to lead and design that our hospitals are big in our community serve many things we're redefining but can you imagine if we can align together take away the skepticism and the suspicion and align our resources and our intentions for the greater good we're there the hospitals are there we're funding so much of this right now we're totally in and I think the word alignment is powerful and I think Vermont we're unstoppable if we can do that so thank you for that so at this point I guess we'll follow that's okay so my my question kind of goes back to the slide that was the crossing the shaky bridge two thoughts crossed my mind was that the cost shift makes it pretty shaky as does the resulting impact on insurance premiums especially for people that don't have the help of an employer like those in the QHP population and so as an example of the magnitude of the cost shift I think we can look at the last 2019 hospital budget process where they asked of the hospitals collectively was $85 million and the hospital projected that they would only get 3.4 million or 3.9% of that from Medicaid and that they would get 64 million or 76% of that from commercial insurers and so as that commercial insurance pressure translates through to the rates setting structure we have premiums out there for the low cost bronze plan in Vermont that if you're below 400% of poverty it's $150 in month premium if you're above 400% of poverty it's $150 in month premium a huge increase with very large deductibles of 5 and $6,000 so I'm just wondering if you at the hospital level or Jeff's collectively are seeing that there might be some collateral damage here in terms of this transition from fee for service to fixed prospective payment as costs are hopefully trending down is improving but till we get there we still have these costs in the insurance system that are putting some promoters in jeopardy that's a dangerous thing the cost shift of course is the symptom of underfunded government programs and that's something we need to that the hospital association not just mine but the national one and ones across the country are paying attention to every day look I think Eric's slide was really effectively symbolic because you know the metaphor we use here in Vermont more often is a foot in each canoe and making that transition and all of the sort of downstream implications of that from what it means for the cost shift to what it means for risk are things that we're grappling with and things that I think any health reform journey involves some stumbling picking yourself back up and I think we have to figure all those things out as far as sort of the dynamic from a more financial standpoint I would want to phone a friend or ask someone else we have questions here Dr. Gess Hi, I'm the executive director I'm a family physician in the rural clinic in Cambridge, Vermont and also an addiction medicine specialist in Burlington I think Mr. Palom did refer to the issue of what sounds like the underinsured or as I like to call them partially uninsured and 36% of Vermonters are partially uninsured 3% are completely and as a primary care doctor in independent practice we still actually have paper charts we're seeing patients that self ration care because let's face it primary care is pretty much the only discretionary care that people have when they have huge out of pocket costs and to me that seems to be the huge linchpin because I see people that avoid care and are sicker as a result and we know studies show that they're sicker, they die younger as a result of having no insurance or bad insurance so I mean it really seems to me that this all begs for a system and we are talking about a delivery system and changes to that and delivery system costs but we're not talking about patient costs and that is crucial to the quality of care that you're all talking about I have been you know screaming for single payer for years I still am but we are we're actually proposing that we have a publicly funded universal primary care system that would include mental health and substance abuse services publicly paid for so there would be first dollar coverage which could marry with this ACO because it seems to me that if we encourage people we'd probably be a great I think it would be a good recruiting tool for primary care physicians and there's practitioners who want to stay in Vermont and be here we know in Rhode Island it was very effective in terms of reducing their overall cost when they increase their spend rate but now we're talking about in helping patients and Vermonters, every Vermonter so that they could afford those out-of-pocket costs and wouldn't make those self-rationaling decisions and Mr. Shell I really want to put the spot on you A couple things that really resonated with me is the system and I get back to the systems of care around the aggregating payment system of a population based payment system and the need for aggregation and coming together so that's that's one thing and I think is the farther we move along towards this progression of payment we are going to see that aggregations people come together in systems in terms of the patients themselves and the cost of patients one comment was I talked about the fact that essentially we've gotten too expensive and we've got to give back we have got to give back to GDP our confiscation of excess of dollars we've got to create systems we've got to reduce some of the supply of sick care services we've got to invest in health care services and give back to GDP and make us a lower cost system overall for patients in terms of individual patients and the dollars that they're paying you know charity care programs discount programs all kinds of things out there offer one-on-one patients especially when you're in your private practice and you have to keep the doors open next you had a lot of study publicly funded primary care well I'll take a few quick questions how about the rest of the panel so just in terms of publicly funded primary care so I do believe and right now we're spending a fraction of what we should be spending in primary care right now there's proposals in front of the American Academy of Family Practice around kind of doubling the investment in primary care to create some sustainability there and some investment that whole team-based care approach where we leverage up the primary care doctors with advanced practice providers nurses others and get that out there now I do think that that's the case and I think Washington DC sees that as the case that we make this excess investment in this primary care model and I think we're going to see some opportunities in the next six months but how we fund that publicly I'm not sure I'm willing to comment on that so the key goal of the all-parent model is to try to make more emphasis on primary care and I just want to stress that you know Davis yes this is a comment concealed in a question about everybody I'm curious about what they think about the political slash regulatory environment that our whole project is working in what we really have here it seems to me is a split between the great legislative power of the Green Mountain Care Board but without great knowledge of the details of the medical delivery system on the one hand and then one care which has which is the repository of the medical judgment of the medical community in Vermont but without much political power actually not much political power so my question is this in Eric's comments which are by far the best analysis I've ever heard about the way that the market and price forces and supply and demand and all of that begin to operate on the system and then Steve's comment that who's the real decider here and it's the boards okay it's the boards of these hospitals I just want to ask Steve this he's in southeastern Vermont okay in southeastern Vermont some years ago and I was a regulator we had Springfield we had Rockingham and we had Brattleboro right now we have Rockingham hospital is gone Springfield hospital is really really hurting that's the most polite way I can do it and what's left is Brattleboro on the one hand does Steve really think that the boards in Springfield and the boards in Rockingham Falls really decided they didn't want a hospital is that really what happened I don't think so my second question is I'd love to hear Eric take his really incredibly illuminating view of how the cogs and pieces of this system work and ask him what he thinks it's the political environment set up in Vermont sorry about that so long thank you am I responding to a question or a comment I think it's incumbent on the boards and incumbent on the CEOs to educate so that the community is never left without access to care whatever that might take form could take form of FQHC which Springfield similar to Dan's hospital the hospital actually reports up to the FQHC that's a requirement from FQHC that can't be owned by a hospital but I think it's incumbent on the boards to think about what's it going to look like in five years what are we going to look like in ten years and our board identified those services that are critical to our community whether it's emergency department primary care is always number one so it's not that the board makes that determination it's the environment around us that puts pressures on the board that has to be educated to respond to those pressures you know in Brattleboro's case we're not going to be the last man standing obviously in southeastern Vermont but we're focused on our partnerships with Cheshire Medical in Keen or with Dartmouth and you know over time and we've had the strategic partnership over time that relationship is going to continue to grow and evolve probably similar to what you've seen in other hospitals like Mount of Scudney becoming part of a system and I might be provocative but I think over the next probably five years in Vermont you're going to see something very similar to what happened in New Hampshire a hospital corporation of America Hospital an HCA hospital for 13 years in Derry, New Hampshire HCA is the largest for-profit chain in the country and we had Derry and we had Portsmouth now HCA is picking up Exeter Hospital Mass General I'm sorry not Exeter, Frisbee Mass General is coming in to Southern New Hampshire and picking up Exeter Hospital and as Kevin said you're going to have out of those 26 hospitals one or two still independent that's what's going on in this country because we're going to continue to get squeezed on our overhead whether it's how many CEOs you have how are you going to pay for your your expenses, your back office functions, centralizing those I think you're going to see over the next five to ten years substantial changes in the landscape of Vermont similar to what you've seen in the rest of the country and what you're seeing next door as well as the CEO in Massachusetts for several years how many hospitals are still independent in Massachusetts not many, not many and even now the systems in Massachusetts like LEI and BI emerging so it's a transformation and we're responding to the needs of our patients the needs of the regulators the economic realities that we're facing and we're going to continue to change and to evolve I don't know if that answered your question but but I think it's really in response to the functional imperatives what do you have to be successful under a population-based this new payment system and it's aggregating lives to diversify insurance risk in scale to diversify cost as well as create systems of care to manage the entire range of the scope of services that are going to be necessary for a population and that's why when you said in five years it's likely Vermont's going to be rolled up just like others I agree with that completely but it's to meet these functional imperatives of a new payment system but my question is what do you think of this political spectrum we have to get there the goal is clear let me just say that I haven't been in Vermont since we helped convert Middlebury to critical access hospital several years ago other than passing through from Albany across the Green Mountains so I laid out a case for how I think just the economic forces are going and the imperatives and what's going to happen but in terms of what's going on here politically I think either Kevin or Jeff would be a much better position I will say full disclosure that my firm Helms & Company was the firm that was brought in by Rocky Ham Hospital and to Steve's point what we did, I wasn't there but my partners who have long since retired tell me what they did was they educated the board about the economic reality they also looked at the population that was being served they also looked at what services were available in a reasonable geographic distance around them and then they asked the board what services are we providing that would be a hardship for our population to get elsewhere that we can provide in a competent quality and effective way and oh by the way they added to that we've noticed that five of our board members have got surgery and all of you left town and went to another hospital to receive that surgery and when the board really went through that thoughtful process weighing all the different perspectives they came to the decision to shut the hospital down and then Vermont's regulatory structure and given the goals of the all-payer model the most important thing we can do is make sure that we're staying in partnership with the Green Mountain Care Board and I think that's been happening more and more with hospitals telling their stories having individual dialogues and just trying to make sure that we're working through all those questions together Okay we have time for one more question Susan I'm Susan Aronoff from the Vermont Developmental Disabilities Council and this is for Eric I don't know if it's possible for you easily to pull up your slide number nine where you've had the Interpose Rule rating increases at the rural hospitals This was a slide on the inpatient proposed regs that were finalized in August where rural hospitals received an update factor received an update factor of 1.1% One more So in the circle for rural hospitals it's 1.1% Below that it says major teaching 2.6% I was wondering if either you or maybe the guy from OneCare could talk about how this payment model Sorry Kevin How the all-payer model will ameliorate maybe you could just say what's the take away, what's the implication of the difference between 2.6% increase and 1.1% for teaching hospitals rural hospitals then my real question is how would the all-payer model mitigate or ameliorate the impacts of that paid differential for our rural hospitals The way I look at it is when costs are going up 5.5% whether you're 2.6% or 1.1% either one of them you're behind the game and leading to those increased negative Medicare margins and so I knew at one point the difference I thought it had to do with site neutrality on provider based practices of hospitals and rural hospitals I think that's had a piece of it and it also had to do with the 340B program I'd have to go back and do the right but I think Kevin's probably going to be a that guy I grew up in Halifax Vermont but I left when I was 18 so I knew to be back in Vermont so at the ACL level we do not do contracts and payment arranges with the providers we live with arrangements that the various payers have in place with their providers what we do is we take responsibility for the aggregate spend but what we can do as I mentioned in my presentation we do under the ACL have the ability to move some money around so we do have the larger hospitals make a bigger contribution to the population health investments and to the cost of ACL operations so that's one way we're able to get some support from the larger hospitals but we do not do contracts with any of the providers it's the rates that are negotiated or agreed upon or set by regulatory statute that we live with on all of our beer contracts so if I understand you whenever in hospitals one compared to another the payment model from the ACL doesn't impact that differential the reimbursement that providers will see for the services rendered does not impact but we are responsible to work within that fixed budget so if the spend goes over the fixed budget then there's going to be repayments essentially but we don't get into setting any reimbursement rates between payers and providers so with that I think we're going to try to wrap this up since we're already over time and again I want to give the panel a round of applause so I'm going to shove up a few lines and see if we can forward so on the next slide we're going to get this whole business and this whole business and we're going to go forward and you were questioning this because of the question of what is the board that's going to be tender when it comes to the hospital so we're going to go forward and we're going to go forward and we're going to go forward and we're going to go forward and we're going to go forward and we're going to go forward and we're going to go forward and we're going to go forward and we're going to go forward and we're going to go forward and we're going to go forward and we're going to go forward and we're going to go forward and we're going to go forward and we're going to go forward and we're going to go forward and we're going to go forward and we're going to go forward The motion to shut down the home page and number one to second rid of it was to help rebase it and have it send it off to the fire department and help the staff predication that had to ask for the hospitals to be prepared for two percent error, set with the hurricane rack, set with the national budget to submit FY19 budgets to block those who are on with their 17 actuals and 18 rejected actuals. There was some discussion in the discussion that the member of Helen raised concern about making the midyear adjustments and expressed a design of the TNAC approach. So if everybody could take their conversations outside of the auditorium? Holmes responded, clarifying that the motion was not for a midyear change. It was instead intended for guidance on hospitals on how they should build their FY19 budgets. The motion was approved. For the one vote, member of Helen voted no. There was no order issued amending PBMC or Porter's FY18 budgets. Obviously the rebase was discussed and incorporated into the 19 guidance. And that's basically the extent of what I did to look into it. Again, I think it's really a question of what did the board intend when it rebased the budgets? Did it intend to actually change the 18 budget in the initial order? Or was it intended to set a new starting point for FY19? There was no realistic in line with actual performance, both 17 actuals and rejected 18? Questions of Mike? Okay. So we asked the general council to come back with questions. I don't think it's fair to let this linger if there's an interest in having additional enforcement hearings. I think we should decide sooner rather than later. I'm not saying that that necessarily has to be decided today. I think ideally it would be wise to decide it today. But at the latest I think next Monday would be the absolute limit. And so at this time I'll see if anybody has any motion to offer. Maureen? Well, I think maybe have a discussion or do we have to have a motion first? Discussion is fine. Yeah. You know, I think the intent when we did the, what I perceived the intent was when we changed the rebasing was for 19 budgeting so that we could make sure that we understood that 17 came in higher and let's roll the trend for 19. I think we were silent on what that would mean if anything for 18 and enforcement. And I think in consideration there are a few factors that would go into consideration. There were two hospitals that we changed. UVM and Porter. UVM at the time we did do enforcement and Porter we did not do enforcement because again this is what my perception was for Porter. You know they're really just coming out and improving their operations, shifting in with the network and you know had not yet really seen a big change. I would say with looking at the performance for 18 on both the top line and the bottom line so the top line would clearly know there was over 2% to their budget for both UVM and for Porter but not to the rebase and profitability for UVM was less operating margin slightly higher total margin. Porter was up significantly for total margin including some adjustments they did for reserve. So I think we didn't do anything for enforcement on Porter in the past last year and so I do think that we should at least have the hospitals present and I would actually say you know this is up for discussion but as far as for UVM whether we actually do any enforcement or we have a review. I mean one of the things that I have pushed for in the past is that we really only formally see the hospitals under the budget process and then under the 18 actuals or review if we or the actuals for review if we bring them forward but it's not part of the process for them to come in. I mean and some hospitals come in for other reasons but I think it would be worth the board hearing from those hospitals particularly the largest one in the network on what's going on, what happened for 18, where they're trending for 19 and you know whether we make a decision now whether that's under enforcement or under a committee with us so that's kind of my take. So I do think the board needs to make the decision about whether to bring enforcement or a discussion and presentation. I don't know if that needs to be made today but I think before we send out a letter the board does need to make that decision. Okay other discussion from the board? I'm happy to chime in. I think that while the rebasing was designed to fix, to sort of write budget and reflect the reality of the 17 actuals for fiscal year 19 to make sure that budget reflects the reality the fact that we actually allow that increased volume or increased utilization into the fiscal year 19 budget in some sense validates for me at least in my mind that validated that utilization was real the extent that UVM had been having large volume for 14, 15, 16, 17 years going over for several years and having this volume that just moved through the system we finally rebased in 18, 4, 19 that's the same volume in fact that volume overage was what we enforced when we asked them to reimagine the mental health in patients so in some sense they've already been enforced on that same volume so having them come in again to me doesn't make a lot of sense because it's the same volume that we've right-sized it, we've moved forward their actuals came in 0.14% over that rebase so they pretty much hit for 18 what we right-sized them for. With respect to Porter I think that it's true that they had some financial difficulties over the years and I think what some of that increased volume was to some degree wasn't a result of that affiliation. That affiliation first of all gave them branding which increases volume but second of all it it's also a function of sending the care down from the medical center back into the community right care, right time, right place and so I think and they came in 18, if we look at their rebasing they came in 18.64% under so my sense is the rebasing made the appropriate budget adjustment and to go back and enforce at this point doesn't seem to me to make as much sense as saying if we've got it right now let's move forward. I just want to add another comment which is one of my concerns is that these two hospitals came in in August of 2017 and presented us their budget for 2018. At that time they had 11 months of data that they could be working with even though their budget presentation may have been based on six months of data they're a sophisticated network they had ten months of actuals at least through July and you know we were mid August and so I just feel that they owned that budget they came in and presented that budget knowing where 17 was trending they came in and met exactly or pretty close to what we had given for guidance and I'm just not sure at that time how they could not have seen that they would have need to have had a higher number and why they did not come in at that time with that and that's one of the things that does bother me because you know had they come in at that time we may have made different decisions if they come in and said you know 17 is going to be much higher we need to make 18 higher but whether that was an actual choice to wait until enforcement or whether it was we really think we're going to come in flat to 17 and that's what we're going to put in 18 so that's what bothered me a little bit is they owned their forecast and they came into that in March when the actuals came in for 2017 and we had you know at that time the knowledge of what their budget was for 18 and they would have had to come down year over year for 18 and then from that we would have built 19 because we built on the budget we said wait a minute this doesn't really make a lot of sense let's you know pro forma adjust 18 forward or 19 forward from 17 and that's what we did and kind of disregarded where their budget had been for 18 you know so that's part of the reason why I would at least like them to come in and have that discussion because I don't want to perpetuate that situation coming to you know as we do the 2020 budget the other thing I have said in the past and I will say again it's you know I kind of don't think you need to pay for your savings twice and we did we did do enforcement for UVM last year and you know then they came in what we would have given them is 3.4 percent year over year we didn't do anything with Porter we kind of put that by the wayside say let's see where this shakes out and then that's why you know I feel that possibly for Porter we should look at some enforcement for UVM we did make adjustments the year before and then we did again you're kind of based in on that same base you know however I do think there should be some response from the network or the hospitals in this case is why did they come in here and present that budget in August and I believe I'm pretty sure we challenged that in the budget process saying you're tracking way ahead are you sure this is where it's going to be because at that time you know the reported numbers were through I think about April so they had six months of data they were tracking ahead so I just want to make sure that everyone's taking our process seriously when they come into budgets and that you know the best budgets are being presented and that you know they own that budget we made the adjustments to rebase it but at that time didn't do any enforcement so that's why you know I do that there is a responsibility like one thing I asked you to look into I have this very recollection that they asked to rebase earlier this wasn't their first request to rebase but we had denied an earlier request did you find that out at some point earlier then in 18 that they had they had recognized UVM had recognized this volume flowing through the system and had asked for it or not is there the only time I know that there was a rebase for UVM is when they came in for actions 15 requests 15 came in and then they said they wanted to use the excess for community housing community health needs for housing and then they were going to adjust the commercial rate and that was approved for fiscal year 50 which would have gone into their 17 budget so 17 kind of was rebased and then for 17 I have not been able to see any request in my documents but there was a as of January 2018 of their 17 data they said they were already going to take over but they were going to take a zero commercial rate and that was the only piece that I saw they didn't say anything about being rebased I might have misunderstood I might have I trust your I'm also probably not in the for some of the data and I think what we have seen is hospitals have come into the budget process and asked for amounts over since we go budget to budget which there's some issues with doing that hospitals have come in and asked for higher than that and have reconciled why they need that at that time case in point southwestern and these hospitals had the opportunity to do that when they came in and they could have said look we're tracking way ahead for 2017 therefore for 2018 we really need to make some adjustments and we may have made different decisions at that time during the budget and we didn't really get an opportunity to discuss this with them, get the rationale for why they came in with that budget and how they could have done that differently and I just would hope we won't have anything like this repeat again so when hospitals come in for budget they realize they need to tell us what's going on and where they're going to be and they have the time at that point to make some adjustments to either keep within the numbers that we get or support why it should be higher case in point in our budget guidance we also have the opportunity for all hospitals to let us know if they need to have the budgets amended in the guidance, it's a policy for a rule or a guide and even in their old they're supposed to notify of any any changes that may occur that will make a difference so Robin? So I think the way I'm sort of thinking about this as we're discussing it is I do think that to your point Maureen, we're silent about 18 enforcement and so that's it's kind of handy that this is coming up now even though it would have been nice to have thought about it when we talked about it then because if we do go into the next round of enforcement with the other hospitals and we're talking about rebasing it something we should try and think through and be clearer about so that's one major takeaway for me that's not directly on point to whether we should bring these two in I think if I certainly want the hospitals also to take our process seriously and to update when necessary because without that I think it harms the integrity of the regulatory process I feel like that's a better discussion to have separate from an individual enforcement because to me the enforcement is really about why it are the numbers different than what was expected in terms of and whether that's something that we should try to modify through a future action so I think where I'm at is because we were silent on it I would not necessarily enforce an ambiguous situation like this but I do like your idea Maureen of having realities and those realities as Maureen was saying they had ten months of data the budgets should reflect the reality of what they're observing if middle ground here might be drafting a letter to the hospitals articulating the importance of of our process and of the expectations of what goes into their budget submissions reflecting their actual and to the extent that maybe a meeting with Kevin and some of the hospitals not in a formal hearing process but in an informal setting middle ground I think where I'm conflicted is I agree with Kevin I don't think we were completely silent I think I also referred to what we were talking about the mental health and giving back the 21 million that there may be more depending where they came out the next year and if they were over in 18 which they were not but what's not clear is the guidance that what we decided last week was that any hospital that was sent over we were bringing in 2% over budget these hospitals are 2% over budget and without having a clear direction on is the rebase the new budget which I don't think we ever said that it was the new budget for 18 when you read all the documents and even some of the documents that were sent from UVM back to us they were saying we need to adjust this so that we have a 19 budget base to work from so we can start from this number for 19 so I think we were pretty clear on that and I think the other thing that we did is we said we're bringing hospitals in who are over 2% of their budget and they're over 2% of their budget in these cases so I'm not really sure how that would then say we don't need to do that because we adjusted midyear we adjusted midyear for 19 we didn't have this problem 3 years in a row is the way I was looking at it from 17 but again I just feel they owned their budget in 18 with 10 months of data and they didn't come in with that and they still should come in for a discussion whether or not we do anything is we'll be up for discussion and I can see the way this discussion is going I'm not sure that we would necessarily do something but I think having that review based on what we said which is those 2.5 you know minus 2.5 and plus 2 I think the part that I'm struggling with is if we brought them in for enforcement and we wanted to do something we've rebased 19 so what are we going to do I mean it's sort of that's why I see it as hard to look at it in enforcement because usually what you do in enforcement is in the like you're adjusting something in the future but we've already adjusted something in the future so that's just where I intellectually I'm struggling with with it as an enforcement action per se because I don't I think I don't quite see what the possibilities are now we have time between now and you know if we were to have a hearing to try and figure out what the options are but that's where I'm kind of stuck I guess and I think there are options you could even produce the commercial rate there are a number of options that could be there but with that being said if the argument is just that the demographics changed which we agreed to and we're going to do it at the end of the day I would hate to see us take an action against a hospital that has already committed even though the enforcement last year was for setting aside 21 million dollars on the inpatient and Cuban psych beds it's going to cost a heck of a lot more than 21 million I think we all acknowledge that and so I think at the end of the day what it boils down to is whether we think it's worthwhile to call the men for consistency and have that discussion with them or if we say for efficiency we won't put them through that process because we can't see ourselves taking the correct action then we don't call the men and that's just for UVM I think UVM and Porter are two separate discussions here and to me I don't care which way we go I just wish we would make a decision quite frankly does anybody wish to make a motion so I would just ask my colleagues to realize that it's not fair to leave people outpanging either and that I would hope that at Monday's meeting we could make a decision one way or the other you're free at any time alright I would make a motion that we bring in Porter a discussion based on being 2% over and not taking any action last year on their overage and we do not bring UVM in on an enforcement hearing but we do have them come in and present to us on just an update of what went on in 2018 and what's going on in 2019 which I think is a good practice to do with the largest hospital network to have some more public conversation about what's going on okay is there a second I'll second for purposes so that we can actually discuss thank you Robin discussion Tom I'm just glad I voted no I know I look back on I don't remember March and there was a presentation back then as to what to do with the 2017 surplus and my approach was to put 7 million bucks into the mental health issue in the remater into a charge reduction and when that didn't prevail I just presumed that the projected overage for the 2017 was kind of built into the base kind of right sides it but I'm not going to I don't want to put myself in the position of trying to interpret what the rest of the board meant because I voted the other way and so whatever kind of gets us on the best track with UBM in this regard something I think we should do so Marie I'm going to ask if we could divide the question and I think UBM discussion first and I think what I heard the motion was to just ask them to come in and discuss the budget I don't see as big a time crunch on doing that since it's clear that there would be no enforcement it's just a discussion so I think that that could even be just you know scheduled for a couple weeks out so does anybody wish to have any further discussion on calling them in just for a discussion on their budget okay all those in favor signify by saying aye aye all those opposed so I think I heard four to one okay so the second question is whether or not to hold an enforcement hearing for Porter and is there discussion on that so for me with Porter I agree with Jess that I feel like I've heard that the rationale lasts with the 17 enforcement and I think with the previous budget submissions or presentations where UBM talked about their service realignment where they were moving services back to the community were more appropriate to that community thus quite frankly freeing up capacity of the academic medical center for more complicated or more acute situations I see that in 17 I was convinced that the budget overage at Porter was a result of that service realignment and I do think it's appropriate realignment so I and I don't think we're going to see a difference in explanation for 18 so because of that and because of the rebase I would recommend so that's where I am on that one so I'd like to ask a question I'm not sure if Lori might have an answer to this I know it's putting you on the spot or maybe Jess would have an answer as the Dean of the Board you know she needs to be called that was there a period Porter was going through their period of struggles where they had a decline or less than a growth rate in the NVR than the other hospitals that once they got back on track they caught up to that does anybody know the history I definitely know they were struggling I would have to see some of them art charts but the way I understood they were starting to be in the black in 17 and 18 the question really isn't about margins the question is what their growth in their revenues were do you have any recollections Jess I wouldn't want to put a number on it I know they were struggling their days cash on here were quite low they were in the red we're flipping through papers here I think they weren't meeting in the end that's what the question is really I don't think so Porter for the last four years on NPR went up 5.8, 6.3, 4.2 and then 2.7 from actual and Porter from an operating margin and so I understand what you're saying Robin about we went through that last year but we didn't make any out of this is not just top line it's contribution right and it's like if they if they're making a lot more than what they were projected to make how if at all do we get that back maybe to whether it's rate payers or to the community and their budget for they had the largest shift in their operating budget from any of the hospitals they were projected on on a margin to lose 2 million and they made a million five but on a total margin they're projected to make a million and they made 5.3 which is pretty healthy on where they were and again I don't know that we will you know when we get to enforcement whether or not we will enforce but that was the difference between last year because they weren't had made that change in profitability and this year if they did what the difference was on that you know last year we opted not to do anything because they were not financially healthy when we go through it we may still say look they've turned a corner but they still need to get reserve set for the ACO we don't want to do anything any other discussion I guess I'll just share that I'm cognizant of the administrative burden that we place on hospitals and we heard that a little bit in the conference today and that's actually why I voted no on the UVM decision was that I didn't feel like I would learn anything new it's not likely that we would do any enforcement which actually we all agreed to and we're imposing an administrative burden on this hospital to pull together presentations which frankly we already have the information about why the actions were what they were and so I just want to add that into people's decision matrix is what kind of administrative burden are we placing on hospitals and sending out budget guidance they're also being asked to respond to our quality indicators and submit a new budget I just want to add that to if I could just comment on this one as well the first I knew this was an issue was yesterday when I got Mike's e-mail and I might have missed something in my e-mail chain but in your e-mail you said that some board members have been talking about this and I was totally out of the loop on it because we didn't so I haven't even gone back and tried to refresh myself as to you know I'm sure you scribbled something on all the paperwork back then and kept it so I feel I feel a little bit seen in terms of this conversation because you know my vote was a negative vote and therefore it didn't matter to an extent and I only found out about this as an issue late yesterday afternoon when I got Mike's e-mail so I just want to point out that the meeting on March 27th one week ago the 27th it was decided by this board you were present to ask Mike to come back to us at the next meeting when we would make a decision it must be a senior moment or something I just the first engagement with it you know yesterday and didn't know where it was because I had not gone to Mike about this before I wonder if the maker of the motion would be willing to table it until Monday give us a chance to go back and look at 2013 and 2014 and see what happened with their NPR in those years of time period where they struggled I could be wrong but I'd rather have the factual information in front of us clearly Tom I think you would appreciate a few more days and hopefully we would make a better informed decision is that okay Maureen? that's fine so without objection we're going to table the motion until Monday's meeting just on quarter Maureen Kelly if you could start to do some digging for us that would be helpful so with that is there any new business coming for the board seeing none is there a motion to adjourn so moved second it's been moved in second to adjourn all those in favor signify by saying aye aye any of them


Well, it started in 2001 when I joined some of the guys in Brazil that were interested into bringing OpenOffice at that time for Brazilian Portuguese, then I got involved with the community in Brazil and I started to help them to translate the software for Brazilian Portuguese. Since then I got slowly involved much more and more into the OpenOffice community. We also developed the community in Brazil. We even founded an NGO in Brazil to give us legal shelter for the Brazilian community. We also had an issue with the names of OpenOffice back to 2007 because the name was Trade Market in Brazil. We had to change the name of the community and the NGO and we called it BROffice. Back in 2010 with the appearance of LibreOffice it was a natural move to bring BROffice inside LibreOffice and after that we abandoned the BROffice brand and we stayed with the LibreOffice brand and my participation in this activity was not only by one of the founding members of the Document Foundation so basically we continued the work of translating and keeping the software updated to the latest releases. So the activity in Brazil is quite intense in the last decade. Today I am coordinating the documentation for LibreOffice. It's an interesting job because I think that in my personal view it's not a product that the Document Foundation should be considering as a collateral to the software and also what is important is that documentation is also an easier way for non-skill developers to participate in the project. So at the moment we are making a way to make it easy for non-developers to really contribute into our documentation. We built the question and answer forum which is the Askbot. We also created a documentation specific website. The two are linked now with the software so for the user it's now very easy to get to the documentation and we have plans to make it easier and more dynamic the help content that we have in the software. So modernization of the software, of the help content, creation of a specific website for easy access to the documentation and also an active and dynamic question and answer forum for the user. So the idea is to bring LibreOffice more close to the user and let the user more comfortable in using the software. So far what we have detected which is interesting is that there is a strong demand on documentation on Calc and Writer. These are the two models that are very well used and people seem to lack the availability of an updated guide for these two software. So this will open us a very interesting perspective in the next six months to twelve months to address this demand that is already there. Yeah it's a good point because one of the things that in the last six months we had is people approaching the documentation team and say I want to help how do how do how can I start helping the documentation. So when they decided that they want to build a new page on the help it's so hard for them to jump into XML and write things and test and build and compile and such and such that I decided to give to the to the newcomers the idea of please write a page in a document like Writer with this with this content that has to be this this and this topics that you will fill with your experience on a specific feature that you're writing about. So people wrote about the the subject and then sent to me and then I take the content and I transform it to a help page. It takes a lot of time it takes for me I am skilled in the in the issue but it takes for me about five to six hours to really finish a help page by hooking into the code. So this is not acceptable I mean it has to be more easy. The idea is to since we have this very old technology that was built for 10 years ago it's time now to modernize it. So let's let's look again to the contents of this XML and let's try to make it more easy for the user. So why an XML is not not needed anymore because basically what you use is to display contents it's not to you don't use the the feature of XML to exchange information it's just display. So if it's just display let's go for HTML then if you come if it's possible to go to HTML then you have an enormous amount of tools that helps you to edit HTML in an easy way. You have online editors you have offline editors it's much more easy what you see is what you get. So let's start to build an environment to make it easy for the user to or to the volunteer to jump in the the health system and correct updates or even create new pages in the health system and this this is a project I would like to carry in 2017 in order to get the users and the newcomers in a in an easier way to contribute because you see one of the interesting approach is that people that wanted to write are young professional writers and this is I am I graduated into a professional documentation and then I would like to exercise can you help me so this is a good way to get people that has more than quite an amount of skills and wants to exercise with us so it's a good opportunity for them to create their own resume by contributing into our project. Yeah the language barrier is definitely one of the most the greatest issues that we have to have these people contributing to TDF. I can tell you because I am almost kind of official translator for even the community and people really are scared to communicate in English and this this this is a real issue. The point is it's not that easy we really need to have some key persons in the country that can really be sort of leaders on on the local community but it's it's a it's a it's an important approach to not let the leader be a kind of a small emperor and to to shape the community on his own wishes which is not good so it's very very important to always open the the communication between the document foundation and the individual it's important not to have people in the middle to unless it's for just for translation it is important to develop a local open source events to get these people to gather it's important also to find a project and get people involved in the project say for for example translation we in Brazil we have a weekly meeting hang out through hang out with seven to eight people and we talk about issues on translation and documentation so that keeps the community I mean at least the team very close together we have a face-to-face we know we can look at at the face which is also very important for building synergy and we keep this meeting regularly even if the amount of subjects is is small because people we discover that really people like to communicate they really like to communicate and and they also are very proud to be part of a team so if we if we can build a team that has an interesting mission and it's it's good for their own their own developments then you have a winning team for open source


I had reached my kind of my limit. And it was time for me to break fear of fear. I was afraid of fear. That's why the company is called The Fearless Man, because I'm always facing more fear. What can I do to step to the next level? How can I step into more tension all the time? How can I keep moving in that direction? Because that's what grows the masculine. Now, I had a teacher. Who knows who David Nagel? Anybody know? I like to credit anybody if I can. David Nagel is a business mentor. He was a business mentor of mine. And he said something that was really important to me once. And it really kind of affected me huge. And he said that he called it the curse of the middle class. And he was talking about what the middle class values of everything else. And I kind of already mentioned it. Can anybody guess what that is? Security. Stability. The middle class always says, what do they say? Get a good job. Get a good retirement. Don't rock the boat. But as a man, what do you want to do? You want to go out and pursue a dream, right? You want to go out and make something happen. I'm going to go start a business. I'm going to go, I don't know, climb a mountain. I don't know what it is.  But whatever you want to do is going to involve stepping into fear, i.e. tension. It's going to involve stepping into tension. And can you see that that's always going to be stepping out of this comfort zone. That's always going to be risking something, not chasing security, but doing the opposite. But yet, if you're in the middle class, and I'm assuming most of you are, then your programming is don't rock the boat. And this is where men today are losing their sense of purpose, losing their sense of passion. You see, we crave tension. And we've lost the reality of that. We crave polarity, which is what tension creates. We crave it so much that we have to go get regular doses of it, especially if we don't have it in our lives. Like, for example, how many of you go to the movies and love movies that have a lot of tension? Action stars, things like this in it. Who goes to watch movies all the time? Reads books, things like this. What's happening in those movies? You're getting your dose of tension.   And that lasts for about a day. And then your life goes back to being numb again. Because you don't want to step into tension. You want everything to be easy. But if you learn to be uncomfortable, you're going to have a very easy life. If you're chasing an easy life, you're going to be very uncomfortable because we need that tension to feel alive. Now, nothing grows without tension. Nothing grows without tension. Think about it. Even a seed, if I put a seed in the ground and bury dirt on top of it, it has to break through the shell. It has to dig roots. It has to grow upwards. It has to grow into a tree, right? And that's done under tension. That's done under pressure. It has to fight its way through the dirt, sometimes through rock, sometimes through concrete, to become a tree, through seasons, through weather. But in that, that's what makes it what it is. And that's what grows it into a tree. Well, it's the same thing with humans.  Sex is tension, right? And then the resolution of tension. How about sperm? Who's read the book, Sperm Wars? Did you guys know that sperm actually battle? There's sperm that actually have different mechanisms for battling to be the one to inseminate the egg, I think, as that works. And it's pretty crazy stuff. And then it passed a bus through the wall of the egg and then a baby grows in nine months in a womb and is born through the birth canal. The first thing it experiences is a lot of tension. Learning to walk, learning to talk. And then there's this weird thing where we become an adult, we graduate from high school or college, and then we want to stay the same and stop growing. But the nature of life is growth. You can't stop growing or you start dying.


Don't use print on demand. It's dead. There's no money in it. There's no money in it. It's oversaturated. There's no new or original ideas coming out. That's what everyone says, isn't it? True, yeah, very true, yep. Well, I'm here to tell you that that is completely not true. Just the same way that people say that dropshipping or any of these other e-commerce businesses are dead. I'm here to tell you that that is 100% not true. As always, it's as easiest as it's ever been to get into. And because of that, there is a little bit of oversaturation. But that doesn't mean you can't make any money from it. Regardless of the e-commerce business that you're starting, there's always money to be made. A lot of money. So if you're looking to start a print on demand business, then don't start your print on demand business until you've watched this video. So today we're gonna cover why you shouldn't start print on demand, but also why you should start print on demand. Not only that, but I'm also gonna give you a few tips on how you can properly start your print on demand business. So you can get started on a strong foot and hopefully start bringing in some sales earlier rather than later. Now, let's go ahead and get into it. Now before we do get started, I wanna know exactly what you think about print on demand. Do you like it? Do you hate it? Have you tried it? Have you heard of it? Let me know down in the comments below. I would love to hear your thoughts. All right, so first things first, what exactly is print on demand? Well, print on demand is a fulfillment service.   When it comes to what you can put them on, you really have an endless amount of possibilities. You can put them on t-shirts, you can put them on hoodies, you can put them on cups, on mugs, on blankets, shower curtains, posters, mats, keychains, literally almost anything that you can think of, you can print using print on demand. Then you need to have a marketplace that you're gonna sell on that can be either your own website or an already established marketplace. So you can set up shop on something like Shopify, or you can set up shop on Etsy, eBay, and even Amazon. Amazon, however, is a little bit different, so I'm gonna get into that a little bit later on. So just stick with me for a few minutes. Now before we go ahead and continue, I wanna give you all a little bit teaser of something that's to come in the near future. So pretty soon, we are super excited to announce that AutoDS will be supporting print on demand services. That's all I can say right now. I don't know if I was even supposed to say anything in the first place, but take that as a little bit of a teaser for what's to come. And if you're excited about that, if you're excited about print on demand, if you wanna learn more about it, along with the ins and outs of dropshipping, then make sure you hit that subscribe button so you don't miss out on any future videos. Now continuing on, after you choose your marketplace, after you choose where you're gonna sell it, then you have to choose a provider that's gonna print those items for you. In which case, the two most common ones are gonna be Printful and Printify. Now each one of these services provides full on printing. Personally, I have used Printify in the past and these are just a few of the items that you can offer. So here you can see that you can print on posters, on canvas wraps, on pillows, tote bags, t-shirts, bikinis, koozies, shorts. Like I said, the possibilities are absolutely endless.  Again, whether that be your Shopify store or your Etsy store, just a quick note, those two are the most common for print on demand.  Of course, you do have the option to sell on different platforms, but those are just two of the most common ones. Now the easiest way that you can start importing some of these listings into your store is gonna be by simply connecting your supplier, whether that be Printify, Printful, or whichever one you choose, to your online store. So that way whenever somebody places an order, it's gonna be automatically rerouted to your supplier and then they're gonna go ahead and print out the product and ship it to your customer. The process itself is pretty similar to dropshipping except with the differences in the products and the ability to customize so deeply. Now what I just explained to you is called active print on demand. So when it comes to print on demand, there are two different types of print on demand services. There's the active, which is the one that I just explained, in which case you're gonna be working with two different sites.  You would have to be a bit more active with it than you would typically be with a passive print on demand service. Now what exactly is a passive print on demand service and how does it compare to an active print on demand service? Well, simply put, with a passive print on demand service, you're pretty much gonna have everything in one website. Some common websites for passive print on demand are gonna include Redbubble, Teespring, and Amazon Merch on Demand, formerly known as Merch by Amazon. So the difference here is, like I mentioned, you are gonna have just one central website where you're gonna do everything. So on these three different websites, you can go ahead and create your design, make your mockup, and list it directly for purchase from these websites. So instead of going to Etsy or your own website to make the purchase, these services will allow you to sell directly on their platform. That in itself takes a huge chunk of the work out of it. But remember that your profits in something like this could be a little bit lower. Now that you know the different types of print on demand services that there are, let's go ahead and start talking about why some people say that you shouldn't start print on demand. The first one is oversaturation. Well, I'm pretty sure you've heard that practically every business out there at this point is oversaturated.   You're gonna tell somebody that you wanna start print on demand. They're gonna tell you that it's oversaturated. You wanna become a software engineer. It's oversaturated. Everyone's learning about computers and coding. Everything at this point is gonna be oversaturated. There's so many people in this world that it's impossible to have something that doesn't have a lot of people in it already. But that doesn't mean that you can't succeed in any field. One of the main things when it comes to success in any one of these different types of e-commerce businesses is the ability to stand out and find niches that aren't really saturated. There's tons of different niches out there that people aren't into. When it comes to niching down, you can get very, very specific and still have a good amount of people that you can advertise to or people that would wanna buy your product. Take for example, the pet niche. Of course, everyone is gonna be in the pet niche, but did you know that you can niche down even further than just a generic pet? So you can niche down to dogs. Now of course, there's gonna be a lot of people in the dog's niche, not as many as the entire pet's niche, but it's still gonna be a good amount of people. But from there, then you can continue niching down even more. So let's say you niche down to dogs, then you can niche down to poodles. You can niche down to rutwilers. You can niche down to pit bulls. Of course, those are some of the more popular breeds that there are, but if you start looking into it and you start learning a little bit more about dogs and the different types of breeds that there are, you're gonna realize that there's a community for practically every single breed out there. And each one of those communities is a different demographic that you can target. The next reason why people say that you should not start print on demand is because there's no quality control. Well, just like any other e-commerce business out there where you don't necessarily have to see the product before actually shipping it out, quality control can be tough, but that doesn't mean that there is no quality control. There's a few different ways that you can always guarantee good quality. One of them is by simply looking at reviews. When it comes to print on demand, depending on the website that you're working with, like take, for example, Printify, you can choose different companies to print your merchandise. So after you design your product, you're gonna pick somebody to print it. Now, typically you're given these options so you can find printers in the certain locations that you're gonna be selling to. So some are gonna be in the US, some are gonna be in the UK, some are gonna be in Australia, some in Germany, and it's up to you to choose which one you think would be best for you. Now, of course, there's gonna be a ton of different printers to choose from and that's why you need to check out their different reviews. They all have reviews. You can read what people are actually saying about them. You can see pictures that reviewers have uploaded so you're not blindly going into this and just picking a random supplier. If you are, then you're doing it wrong. You need to make sure that you check out the different reviews and see what people are saying. Now, on top of that, you can also order a sample. You don't have to order a sample of every single product that they offer, but you can order a sample of maybe two or three different things and the best thing is that when you do decide to order a sample, most sellers or platforms that you're sourcing your item from are gonna give you a discount. There's always some sort of sample discount so you can sample their products and see if you like them and see if it works for you.  Personally, I've only ordered maybe two or three different samples and for the most part, I just blindly ship them. I just make sure that the reviews are good before actually choosing a printing supplier. Now, speaking of samples and customization, when it comes to customization, while you do have creative freedom and you have the ability to customize practically any product, when it comes to that customization, you're gonna be limited in certain aspects and that's the next reason why some people say don't start prints on demand. Now, when I say that, you're gonna be limited in certain aspects of customization or personalization. What I mean is extremely detailed and creative things.  With prints on demand, that's not something you can do. They don't offer patches pretty much anywhere on the shirt or on a hoodie or whatever it may be. While you can sell your custom patches for people to put on whatever merchandise they want to, you can't ask a print on demand supplier to get a particular hoodie or a t-shirt and just fill it up with different patches with different icons on it or whatever it may be. It's way too much work for a print on demand supplier and it's not something that they're gonna do. Another example could be lately I've seen hoodies or t-shirts that are split in half and they're sewn together with two different parts of two different garments. Again, that's not something that you're gonna be able to ask for. Things like this need to be done in-house. So it's something that you're gonna have to find your own supplier for either locally or you're gonna have to reach out to. People that specialize in these kinds of things. When it comes to things like t-shirts, a lot of the times you can get designs or writing on them that sticks out. Some of them can be puffy, some of them can be like little brick, some of them could be really thick so that way it sticks out of the shirt. Those are things that you're not gonna be able to do with print on demand. So if you're looking to get highly customized with your items or you have a bunch of different really creative ideas with very specific customized pieces, then print on demand might not work for you. Noted. But let's say you have a design that you drew or you came up with using AI or you outsourced, you can put that on practically anything you want. As long as you're printing a design, you're not gonna have any issues. Next up, print on demand has a very bad rep.  The same way they do about a lot of other e-commerce businesses. And please, don't let that deter you away. Think about it this way. People tend to focus on the negative reviews rather than the positives. A lot of the times whenever you go out to a restaurant or to a store and you have a bad experience, you're a lot more compelled to leave a bad review, right? If you have a good experience at a store or just a basic experience at a store, typically speaking, you're not gonna be writing a review.  Because of that, people tend to focus on the bad more rather than the good. But if you start comparing it to all of the different other reviews, you're gonna see that, let's say for example, you have a four or 4.5 start rating, the negative reviews are gonna be minimal compared to the positive reviews. So don't let word of mouth get to you. Don't let it discourage you. And most importantly, don't let it stop you from actually starting one of these businesses.  And the last reason I'm gonna cover is profit margin. Now yes, when it comes to print on demand, you're gonna have a lesser profit margin than you would if you were to, let's say, print these items yourselves. But that's okay because at the end of the day, you're not really doing a lot of the work. All you're doing is just designing, putting it on mockups and that's pretty much it. You're not fulfilling orders, you're not shipping anything, you're not printing anything. All you have to do is create more designs, do a little bit of product research and come up with more mockups. That's pretty much it. Now because of that, because you're saving so much time and you're not fulfilling any orders manually, you have the ability to focus more on your sales and more on your marketing. So while you do have less of a profit margin, you're still gonna be making either the same or even more money because you can focus your time more on actually getting more sales and marketing your products. Now, let's talk about why you should start print on demand. Well, for one, starting print on demand is extremely easy to get into. Making designs now is easier than it's ever been. There's tons of different services online, some of which are completely free that you can use to start coming up with different designs. So if you're not a designer or if you're not really good at it, but you do have a vision of certain things that you wanna print or design, then you can use an online service to help you get started. Now, just to name a couple of service that can help you out with designing. First off, you have Kittle. Kittle is a paid service, but you also have access to a bunch of free different features on there. But just as a quick overview, they have AI tools, some of which can help you remove backgrounds, others are image generators. So you just tell it what to come up with and it'll design it for you. And they also have an AI quote generator so you can come up with different quotes on the fly. On top of that, they have a bunch of other features that are actually really well worth it. So Kittle is something that could be worth checking out. Another option that you have is Vexels. So with Vexels, it is a paid service as well, but you have access to hundreds upon hundreds upon thousands. I don't even know how many they have. Different designs that are actually really cool. Like look at this one right here. It's a variation of a Starry Night. They have this skeleton one over here. They're good designs. They're mature designs. They're not corny. They're not cheesy. But if that is something that you're looking for, you know, like the corny designs, you can look for them on here. And I'm pretty sure you'll be able to find a few of them. Aside from that, you can simply just go on Etsy. You can type in whatever you want. Let's say alien and type a file name right next to it. So PNG or JPEG. So right now I just looked for alien PNG. And these are all of the different designs that they're offering on Etsy. Now, after you have the design that you want to print, then you actually need to make the mockups, which a lot of people think that that could be really hard because of the fact that you might need to use Photoshop. But that's not the case with print on demand. Pretty much any supplier website that you're using, like Printify, Printful, Redbubble, Teespring, whatever it is, they have mockup generators. So once you upload your design, they're automatically going to create the mockups for the different products that you want to offer. From there, you can make any adjustments or you can tweak it however you want before actually making it go live on your site or your store. Now with the integration of the selling platform and your supplier, or by simply using an all-in-one website like Amazon Merchant Demand, you can also enjoy the benefit of automation. So you really don't have to do anything when it comes to fulfilling the orders. Somebody places the order on your store that's gonna be automatically rerouted to your supplier and they're gonna get the printing done and shipped out. You don't even have to pay for the item because you can put your credit card or your debit card in file and it'll be charged automatically. And of course with automation comes a lot less steps, so you have a lot more free time to keep on focusing on your sales and your marketing so you can keep bringing in more and more customers, more sales, more profits. Print on Demand also has a massive product catalog. Like I mentioned earlier, you can print anything from t-shirts to beach towels to even sandals. And on top of that, another reason why you should start Print on Demand is because there's no minimum order quantity. A lot of the times with a certain business, if you want to have customized items, you probably have to order in bulk.  But with Print on Demand, because of the ease of actually printing on these different products, you don't have a minimum order quantity. Somebody can order just one if they need to. So if somebody just wants one mug and one t-shirt, that's perfectly fine, there's no problems with that. And last but not least, when it comes to why you should start Print on Demand, it's easy to go global. You can go international whenever you choose or you can go international from the start. Print on Demand companies have printers all around the world, so you can get your products to your customers pretty quickly. Now just a couple of quick tips on how you should start Print on Demand. For one, focus on getting sales. I know with Print on Demand, sometimes it could get discouraging because you have to offer your products at a lower rate, which means you can have lower profits. But at the beginning, focus on getting more sales. You can focus on raising your profit margins later because honestly, what good will it do if you can be getting some massive profit margins but you're not getting any sales? I would rather have tons of sales with a smaller profit margin than only a handful of sales with a fairly okay profit margin. Because let's be realistic, you're not gonna be able to double or triple your investment on each one of these products. If a shirt is costing you $15 to Print, you're probably gonna be selling it around $25. More than likely, if you sell it for $40 or $50, you're not gonna be getting any sales. So when starting, focus on learning the business, focus on learning what works and focus on getting more sales rather than getting higher profit margins. Later on, once you're established, you know what you're doing, you know how everything works, then you can start to focus on starting to raise your profit margins. Another quick tip to get started on a strong foot is if you're not getting any sales, it's not gonna be because of the business model. It's gonna be either because of your product or because of your marketing. Remember, the business model is not to blame for you not getting any sales. You have to tackle your marketing, you have to tackle your products in different angles. If you notice that something's not worth it, then start to focus your attention on something else. Come up with different designs, come up with different products, try different niches, try different niched designs. You might realize that a certain design will work better on a mug than it will on a t-shirt and then sometimes it'll work better on a pair of sandals, let's say, rather than a shower curtain. Try different products, try different designs, try different marketing techniques, different marketing tactics and just make sure to switch things up. Make sure that you don't spend too much time and too much money trying to market one product that's not selling. And that's why you should not start Print On Demand at least until you watch this entire video. So if you did watch this entire video, huge thank you for sticking around all the way to the end. It truly means a lot. Please, since you made it this far, just go ahead and smash that like button and while you're there, make sure you hit that subscribe and ring that little bell notification so you don't miss out on any future videos. It really helps me out, it really helps the channel and it helps us grow so that way we can keep bringing you the most updated information in the dropshipping and pretty soon Print On Demand business. Once again, huge thank you to everyone for watching. My name is Mario with AutoDS and we'll catch you all next time.


bring it down to 74 and then I'll copy that whole thing and paste it across to the hundred tests that we will make that would have an uneven coin so now we're going to paste all the way across so there's our table generation let's insert a table insert table and so now we have our random generator for the unfair coin so now let's select the whole thing and and make a static test copying the whole thing and put our cursor over here and we'll put it right here and right-click and I'm gonna paste one two three just the values I'm gonna select the headers and format the headers so I'm gonna make them home tab font group black white centered and wrapping the text I'll select all of the data now and let's make that our blue and bordered so we'll select the entire data set and we'll make that home tab font bordered and blue and then now when I do my count if it's heads it's gonna say I want you to say equals count if brackets and then I'm gonna take the whole thing I'm putting my cursor up one control shift up and then shift down now I'm gonna look up here to my formula bar comma if it's a one count it and that comes out to 21 and then I one way I can do the second bit if it's tails I'm just gonna say I know there's 75 of them so I can or 74 so I could just say this equals you know this count of 74 minus 21 that would be the easiest thing to do we could also come up with a with a formula to say count if it's not equal to you know one right and that would give it but but the easiest thing to do would be that and I'm gonna say then the totals and sum them up which of course should come out to 74 and then we can take our percent our percent heads versus the percent tails and then the percent total so the percent head this time was equal to 21 divided by 74 making that a percent home tab numbers percentifying tails is 51 over 74 and we'll say home tap numbers percentify font group underline the total percent then of course summing 2872 is number group percent 100 percent so there we have it if I copy this across it's copied all the way across for our 100 tests so now we've got that copied I will make this something funny happen here hold on us oh I can't I have an issue and that's because I used this 74 and that's not going to move that needs to be absolute so that's r i 7 1 that's our our i 75 so I'm gonna put my cursor in here f4 dollar sign before the letter dollar sign before the number and then copy that across and it should be good to go and then I'll select the whole bottom bit and make it that dark blue and white for our totals down here and so we'll make that home tab font group dark blue and white so now you can see of course if I looked at the percent heads then you're gonna say hey look that doesn't look right something looks leaning towards it looks like it's leaning towards the tails right so if I let's copy all of the heads and transpose our totals I'm just gonna say if I just look at my heads I would expect it to be around 5050 if I go up top and transpose it first I'm gonna right click just the values then I'm gonna copy that and put my cursor in vh right click paste it one pasted special transpose enter delete all of this stuff because we don't need it anymore and then I'm gonna insert a table insert table okay make it a percent home tab number percentifying it so there so there we have our numbers and then if I wanted to say this is what was expected expected and this is the difference difference expected would be 0.5 or 50 percent I'm gonna double click copying that down the difference is 28 minus 50 and so notice the differences are all you know going one way so now we have some evidence where we're saying hey look something doesn't look right according to these tests we have a preponderance of evidence to then reject the null assumption that it's a fair coin which if looked an infinite amount of times would come out to 5050 right in the total population I'm going to delete this now if I make a histogram of this data I'm going kind of quick because we're running long on time I can go to the insert charts histogram so here's a histogram of the unfair coin leaning towards tails and you can see the center of the graph it still looks like it's centered but you could see where the the labels are over here instead of around 50 percent so the center point is spreading out over here which is is not where we would expect the center to be whereas if I copy the the even coin and I copy the histogram we came from that and we copy that over here then let's paste that we can see that the center point is what we would is closer you know to what we would expect so so that's our uh this one still kind of shifting over to the right here a bit that's kind of interesting but you get the point here so you get so so so the idea is is that we would test it the total population is an infinite number of flips here when we compare it to like sampling that we might do in an election so an infinite number of flips which would be 5050 we took a sample which is a finite number of flips and here we've got a preponderance of evidence that certainly leads us to believe that something looks off here we're still a little bit shifted over to to to the right but we're nowhere we're nowhere near as skewed as obviously this one up top and again obviously because it's a random sample we can then get into questions of how close are we to the actual number given the samples which we'll talk more specifically about in future presentations


So my three ingredient hair mask will consist of organic raw honey We have some olive oil plant and Then some coconut oil now. I think I don't really want this. This is a mask So I'm gonna actually use it almost like a pre poo So I'm going to use Probably almost all of this honey just due to the density of my hair between Three-fourths a cup to almost one cup of olive vera And I would say about one-fourths of a cup or three to four tablespoons of coconut oil All right, you guys so this is what my hair is looking like it's very old It's been three weeks since my last wash day Very dry very dirty So I'm going to go ahead and section off my hair. I apply a little bit of warm water growth in water everywhere And I save some of the olive vera plant and I'm going to rub that on each section Doing a little bit of finger detangling here now. You don't have to Rub the olive vera gel directly on your hair, but I felt like my hair needed it and I didn't want to waste anything I'm going to go ahead and and apply the olive vera mixture This is the consistency if I were to do it over again, which I more than likely I will I will put this mixture in an applicator jar to make applying it easier Using the wooden cones to see how well it goes through and of course it goes through really good So all right you guys I'm going to continue to section off my hair and apply the mixture Now the spray that I'm using is actually rice water. I did apply it to my hair Before and afterwards and so yes you guys now it took me quite a bit to detangle my hair I won't even say detangle to apply this into a little bit of light detangling It took approximately 35 40 minutes because as I stated my hair was very old and I wanted to be very careful separating my hair to minimize breakage A bit more rice water I left this on my hair for about 45 minutes and this is what it looks like with the product all rinsed out It is very very moisturized you guys Are you guys I know you can't see me. I have fully washed out all of the product I'm gonna take these glasses off because it's just foggy Um, I like it my sorry y'all my hair feels very very soft now. I will say that um My hair felt heavy and I think it was the honey. So Um, I wanted this to be simple I wish I would use more olive there a plant because I definitely need it more But yeah, I like it. I like it.  Yeah, I would get all extra, but this is what it looks like and it feels soft So that is it you guys. Thank you so much for watching. Take care


Hi everyone, Sean with jaspyscasebrakes.com here doing a random number block randomizer for 2021 Pimini Immaculate Pick Your Team number one, encompassing the Angels Dodgers, Mariners, Braves, Phillies, Nationals, Orioles, Giants, and the Rockies for Immaculate Pick Your Team number one, full case break coming up next. It's a random number block as it says for Pick Your Team number one for the teams listed below, as we just said those nine teams. Every spot gets a random number for the break between zero and nine. If you number three you'll get all cards for those teams with three being the first number next to the slash on the left side of the slash. So if the card is 243 out of 299, 1399, 3 out of 25, 43 out of 49, 93 out of 99, and so on. Number three we'll get the card. All redemptions go to the zero spot even if it is a known one of one it will still go to the zero spot. And any non numbered cards are randomized to the group. I don't think that'll be an issue here in Immaculate but just in case. So here is our list of customers thanks to everybody for getting in from Kenneth Bonnet with the first spot purchased down to Ed Ayrens with Last Spot Mojo and here are our numbers from zero through nine. Dice roll to randomize both lists and pair them up a one and a two three times. Good luck. One, two, and three from Adam down to Adam. Tag that as RMB and three times on the numbers. One, two, and three from zero down to three. So three times on the numbers, three times on the customer names and three times on the dice. Adam was zero, Logan was seven, PJ with four, Alan with two, Jesse with nine, Kenneth with five, Jesse with one, Ed with six, Travis with eight and Adam with three. So let's sort that by number frame it up. So Adam with the zero spot would get any and all redemptions for the nine teams in this random number block including one of one redemptions while Jesse with the one spot would get any live and in person one of ones for those same 19. And there you go. That is our random number block randomizer for the Angels Dodgers, Mariners, Braves, Phillies, Nationals, Orioles, Giants, and Rockies in Panini Immaculate pick a team number one coming up next. I'm Sean, JaspysCaseBricks.com. Thanks for hanging out. We'll see you next time.