Okay. Hi everybody. My name is Martin, as I guess everybody knows. I'm one of the organizers of the conference today, and I'm really happy to see that it's such a great turnout this year. So that we, as the organizers, we can finally see that all the effort wasn't for nothing. So thanks everyone for supporting us. What I wanted to say is I see many new faces. I see a lot of known faces, but also a lot of new faces every year, and especially this year. So just in case that you are a little bit overwhelmed and you don't know how the local community looks like and works like, I want to give you a quick rundown of what kind of subgroups we have and what kind of websites you can go to if you want to know what's going on in the community in Singapore. When you are feeling lost and you forgot all the other links, you can just remember Python User Group Singapore. The abbreviation is like Pugs, Parks, right? So you can go to parks.org.sg and that's kind of our official website for the society. And we kind of try to post news every month and let everybody know what kind of meetups were going on. Like this is like the TLDR for every month, what has happened. So this is a good starting point. I think there are more links to all our subgroups as well, basically the ones that I'm going to show you right now. So if you forgot any of the links, just go to this side. Remember this single side here and you will always have a good starting point to get back into the community if you're feeling lost. I guess the most is going on on the Facebook user group, the Python User Group Singapore, or Singapore Python User Group. You just search for this and you join the group and basically it's an open group. Anybody can post any link, so it's like a forum. You can post questions if you are feeling lost, if you need some consultation about what kind of framework should I use for my next project. Usually if anyone posts a question here, you get an answer within minutes. Good answers actually. So it's still not as active as you would think for a group that has thousands of users, 2,300 users. I think there are like maybe 20 users really active. So why don't we all become more active in this? So yeah, we have another user group called, that's the one that we started at PyCon maybe two or three years ago, PyLadies. It didn't really move a lot in the first year. And then at last year's PyCon, I saw that we have so few female speakers and also in the audience we had very few women. And then I thought, okay, diversity is a thing. Every conference is trying very hard to get better at this. And I thought that we... It looks like your lady. So I thought that maybe we should try to really put an effort into it. And basically I devoted a whole year in trying to grow this community and see how difficult is it actually. Where are all these women in Singapore? Are there actually any? And it turns out yes, there are a lot of them. And we managed to grow this community to 152 members now. We basically try to meet once a month and do some workshops for beginners to just get them into the ecosystem, into the programming language. And kind of make sure that they feel comfortable with the programming language. And they don't feel shy to go to the real meet-ups. I mean, this is also a real meet-up, right? But I mean, eventually I believe that both communities will merge into each other. And we will have 50-50 gender diversity at conferences and meet-ups. I mean, that is like the end goal, right? So just join this community. Whenever there's an event, I'll post a Facebook event. People just sign up and we meet at PayPal and have some pizza and learn something. And especially if you want to present something, reach out to me because we always need speakers. Because right now I'm doing all the workshops and it's taking a lot of my time. So the Facebook group is great for communication, like chatting and asking questions and discussing things. But we found that meetup.com is much better for actually organizing the events. So whenever we have a new venue and we have a few new speakers, we try to do that every month. We will announce it here and post a link in the Facebook group. So it's okay when you just follow the Facebook group first, you will definitely find out about this as well. And usually we ask people to RSVP so that we know how much pizza we need to buy. And please, if you RSVP, you should show up. If you have a stressful day at work and you know that you can't make it at night, then you should un-RSVP because we always have like 100 people RSVP, 150 people are on the waiting list and then only 60 people show up. So 40 people from the waiting list could have a chance if the other people would have un-RSVP. I find this always very weird that somebody blocks a slot in the RSVP list and then doesn't unblock the slot if they know they cannot come. So even if it's just three hours before the event, it's still helpful if you make room in the RSVP. So I just want to get the word out because somehow, I don't know, not everybody is realizing that this puts the organizers under a lot of pressure. So we have the Singapore Python user group with 1,000 members, 1,400 actually. We also have PyData. So I think almost everyone in the PyData group is also in the Python Singapore user group, but as the name says, the PyData group is especially specialized on data analytics and machine learning and these kind of things. These things are really big right now in Singapore. And I guess the data community feels like they have so much more to show and so much more to learn so that they spin off their own user group. It's also quite nice because if you have a meetup where one talk is about web and one talk is about data, it's often that the crowd is smaller because some people will think, oh, it's not worth my time just to go there at 7 p.m. and there's just one talk that I'm interested in. So we feel that it's kind of better to have one meetup that's like two or three talks all about data, two or three talks all about web, and we feel that for each meetup we get a bigger crowd because of this. So similarly to PyData, we also have Singapore Jengrenauts, which is super new. I started that two months ago and we already have 157 members as well. So right now it's again just me giving talks. So if anybody knows a little bit of Django and wants to share their knowledge, please reach out to me. We actually are searching for a speaker for the next month's meetup, for the July meetup for the Singapore Jengrenauts. Did I forget anything? I guess PyData, PyLadies, the Facebook user group and the original official website. That's all you need to know about the Singapore community ecosystem. Thanks.


w we have a communication gap between the most sophisticated operators and member countries and those who are struggling with development issues as we've heard a number of developing countries here air their views and concerns so we have ladies and gentlemen we have a communication issue right so I feel good about the dialogue that we've had but I'm not fully satisfied I'm still hungry and we're running out of time so having said that let me please give the floor to the United States David well let me say first of all I'm not speaking on behalf of the United States on behalf of David Brown there we go this is a Davos type of format I took note of the fact that China is seen if I understood correctly was steadfastly against the idea of IMPC codes frankly I'm a little bit surprised because you know what we're observing in the international market is very important Chinese players like Alibaba and their signa subsidiary building warehouses all around the world including in Belgium and using container shipments and then direct injecting I mean I think there are opportunities for collaboration between Chinese companies and direct designated operators the first comment I would make second I think there's a little bit of understanding about an IMPC code just because an IMPC code is issued it doesn't mean that a member country has to recognize it there is no obligation for UPU countries to accept IMPC codes just because they're issued I think that's a very important point I think that the notion of doing a whiteboard exercise a market test in French pilot project whatever you want to call it I mean frankly I don't want to see Siva Atamir in the Austrian gentleman crying I mean I think that we need to come up with some practical ideas we've heard a lot about market impact analysis we cannot do a theoretical study about IMPC codes we need a market test it's only with a market test let's say with a limited number of countries a limited number of designated operators and interested non-designated operators time limited with a promise that the participants would share data with all you with the secretary with the IB with all a number of countries and then however long did the time limit attested two years or five years that be shared and at the results of that the successes the failures the mitigated successes etc. can be analyzed with actual data I think it's important that you know a country I've been speaking with a number of countries from different continents and made the point if you had a limited test like this there would be no obligation for other member states to join it would be only it would be purely voluntary we've heard some discussion about you know remuneration I mean I think it was clear from the comments of Keith and Kate and others that this would be determined by contract it wouldn't be based on UP remuneration rates I mean unless so happened that the country involved with a dozen operator wanted for some reason UP rates I think that's unlikely I think it be almost always determined by contractual agreements we're talking about commercial clearance not postal clearance but again under the caveat that in the market test if a given country wanted the stuff to go through postal clearance I suppose it would be possible the point is this is something that's important we have to go step by step but I think a white board first of all a white board analysis you know what the parameters be for a market test I think that could be done certainly started between S2 and S3 maybe reported in S3 and then a pilot project of I don't know how many years that would be determined and that would be a step by step most countries in the world probably not want to participate but it would be a very useful exercise thank you thank you David let's go to our friends from Saudi Arabia I will be brief but I'm afraid I'll add to your dissatisfaction Roger let me share from the discussions today the experience we've had with our operator perhaps that will set some light by no means this applies to many other countries it would be relevant to some of the developing countries I would believe just to learn from but our national you know postal player has already lost he's not in the arena anymore a few years ago their market share went down to 6% irrelevant really and we've tried to protect it we've issued decree after decree that government agencies need to use them only and so on so forth but even ministries did not use them all the time they needed much faster much more reliant services and they were willing to pay premium and general public were willing to pay premium for a better service and so on so forth so that war in our country is lost a few years ago and then we've decided if you can't protect them or if you can't beat them then join them the approach we took with our national player is quite different we have closed the government agency that is in charge of postal we have established a subsidiary company of it so it's a private sector company now that runs our postal we got private sector people in the mix of running that company we've injected instead of injecting subsidiaries to this company to survive we've injected money for it to grow its capabilities just 15 minutes ago it was announced that they have bought the largest land company in Saudi Arabia and so on so forth they have introduced digital products they have created three other companies under them and there are more to come they need to be a global player in parcel and in other services as well in order for them to grow and to compete and to play the role that they played very beautifully during Covid which is a national player that can go everywhere we have the approach of protection did not work as much as the approach of giving them much better capabilities and then on a level playground they compete with others there are so many details into that but that's in general the approach we took the final point I want to make and I promised myself I will not make any points because I'm new to this whole postal thing and I'm still learning and it's better to understand first before you're understood but I called the three top players in Saudi Arabia and I said there is a discussion at the UPU regarding I sit on the board of Saudi Accargo as well so I called the CEO and asked them and none of them seem to be bothered by whether they're in or out or whether it even makes any value to them having said all of that and I am outside the UPU world and the postal world but into the logistics one I have seen a lot of products today that would be of extreme value but I don't think they know about them to alter points and so on and so forth I think the marketing and the packaging needs a lot of work and I think there's a lot of value in that, thank you Thank you very much sir and don't undercut yourself that was an excellent intervention and difficult to hear in parts of it I didn't see any other request for the floor so we have a request from the floor from Japan up on the balcony and then I've been told that at 10 after 6 we will then seek the views of our deputy director general unless Vincenzo I'm sorry, right we'll go to Japan and then Vincenzo you have Nerman's got you but you have to wait because Japan's going to go first let's go alright so Japan please thank you Raju-san for finding me so I have to be brief but my view is that it is essential for us to consider the universal service obligation assigned to designate operators we believe that universal postal networks and services would form an essential foundation for underpainting socio-economic development of member countries therefore it is not our desire to jeopardize such an important obligation we have maintained for many years with a solid legal basis in this regard it is essential to maintain sound and fair competition environment between DOs and double PSPs when advancing the opening up in doing so we need careful analysis on benefits and risks of the opening up from the both economic and legal aspects in particular it is important to have a cautious approach when opening up some sensitive products and services that delineates a kind of reason that I hope the global postal network services I'm not sure what kind of products and services belong to that category but according to the survey it might be a remuneration system, IMPC code and postal customs at the same time we can find early harbests in some non-sensitive products and services there might be some IT system and solutions research and analysis services consultancy services and capacity building services we really accept further analysis by the IB as well as member countries for us to have very informed and evidence based decisions on this opening up issue in the coming extraordinary congress we can proceed with step by step approach as agreed in the Abidjan congress last year thank you thank you very much we have a request from the floor from our friend from Russia Oleg please thank you thank you chair I will try to be brief today's discussion has provided a lot of new information and I was particularly impressed by the example from the United States in which USPS is really fulfilling the role that has been allocated and I agree with Vincenzo that clearly we must more actively motivate our services and particularly show our partners from goods businesses to get the right idea and in fact that we can learn something from them we have obtained a whole list of examples regarding cooperation with courier services in particular but currently we don't have any assessment of the negative factors of opening the UPU we don't have none we can do this quite quickly and I propose that we should do this immediately upon concluding this session we need to form perhaps some video conferences so that we can show the results to all of the states of the UPU and under such circumstances I think that the methods of these mistakes that could be made are not correct so we can only do pilot projects when we carry out some kind of theoretical study to see whether we have created the right technical requirements for these pilot projects so from my point of view you're all very well aware of my view on this we are in favor of opening the UPU and we should create a package of new members as quickly as possible to improve competitiveness and we need to be moving on this path as quickly as possible thank you very much Raj and having seen no other people seeking the floor and Chenzo Raj should the agreement flow just for this time ok I will try to be brief and also I'm a good position also to sum up a little bit what we in the last hour I think there are good news for the group led by Peter because at least we assess that basket one it's just a way to promoting products maybe with this feedback from your members also can help us to understand we can jointly work to understand how these services can be announced if there is also to package them and maybe a good idea and why not so I think we already can say that today we concluded that basket one is something that can be let's say open because also was in the request which was coming from the consultation I mean talking I'm talking a kit language so very direct and I say things as they are also I also noted unfortunately that we have some communication I mean because sometime we try to move from the objective of the discussion I would try to be clear before which were maybe because also we didn't attract in this session a stakeholder also interested in some sort of services for instance and thanks Elizabeth for announcing the financial services which are something very relevant in this discussion and maybe we should have invited also stakeholder interested in those that I'm sure they will give a good effort you know to the services themselves not only for themselves but for the postal operators also because we have not to forget that this opening operation should also make postal operator more competitive because it's just the derivative of the process we have to go last consideration the famous sensitive services ampsycode remuneration first of all I have to correct you David I'm sorry about that but if you get an ampsycode and inject anything on the network anyone has the obligation of the leave so it's not optional it's mandatory article one of the constitution of UPO but anyway we know that regulation can be changed so that is not a problem what is the problem I think and it leads with our difficulty in communication and I was announced by my friend here that the products of UPO and remuneration is one of those is a male rotate postal operator so easily we have two options here stakeholders become postal operators and have the same obligation of DOs so we don't have to change services otherwise we have to think of a new system which can be adopted also to new stakeholders David okay so well a right of reply it's more of an informal conversation but listen can you do it 30 seconds and then I'm going to invite Vincenzo and David to go to the consultative committee reception and you guys can go at it I think it will be very good for all the members to watch but David please floor is yours well if necessary we can have a legal discussion of this and I think we have three members of the IB my interpretation is correct in fact there is no obligation for a member state to take an IMPC I know for a fact the United States does not recognize any of the 14 IMPC codes that have been granted to non designated operators which are still valid codes of the UPU the United States government has the right and has exercised that right since at least 2004 not to accept those I just want to make that that's an important point because member countries and regulators and designated operators and other stakeholders based upon what you said Vincenzo can go back and have the misunderstanding for example that if and I actually very much appreciated what Oleg of Russia just said he said we need to do first of all need to do a technical study and that's what we're talking about with a whiteboard because a whiteboard exercise is getting groups of technical experts to come together on how a limited time duration limited member country market test could be done so we could get this technical study going right away and again reporting to S3 on the suggested parameters and hopefully in S3 actually come out with a model for a market test and just because in that market test IMPC codes are issued to the non-designated operators who by voluntary agreement of the member countries in the market test and the voluntary agreement of the designated operators in the market test that they will amongst themselves except the IMPC codes that are issued for the nation for the rest of the world the last point I would make and I've addressed this question with a number of our colleagues from various continents including Africa including Latin America and one point I've made if there were a market test that's done that has no obligation for Zimbabwe Organa or Côte d'Ivoire Bolivia, whatever country you name they have no obligation to participate in the market test but why would you object as a member country to allowing other countries to voluntarily participate in limited study you may benefit from that because two years later or three years later when they come back with the data and the experience from that market test that will inform the entire institution and its member countries on what failed what succeeded and give them ideas for the way forward the last point I would make and I think it's very important is that we've not had any discussion of the sustainable development goals this is a UN institution where all member countries member states of the United Nations and we have these 2030 sustainable development goals including related to climate change I would also add with the pandemic we've seen the importance of resilient supply chains and if we are create in this institution adapting to the 21st century in which it's about trade and goods via parcels we create harmonized, integrated based on the UPU platform where we're not losing volumes off the platform but it's then finding ways that designated operators can collaborate with non-designated operators and other sector players to bring back volume back into the network that's going to help the institution but it's also going to help with climate change David, I'm going to jump in here just because we're very short time but you will be very happy to know that during the POC week there was actually a discussion with regards to the product suite and looking at environmental sustainability and climate change and then during the CA week we also linked during CAC 2 we explicitly linked the UN SDGs with each one of the five pillars that the member countries deliberated so I'm sure that will make you very happy I did want to and I apologize to the deputy director general no, no, no, Vincenzo we got it we got to cut it off buddy I'm sorry I know you're going to beat me up in the parking lot I know I can never make everybody happy but given that Stuart was seeking the floor he's been a very intrinsic part of today's proceedings deputy director general please accept my apologies regarding the timing but Stuart was so kind to give me the floor earlier I know that he'll elucidate us as we bring this to a close Stuart please thanks Raj and congratulations to you and Nermeen for really doing a superb job today on this conversation and really getting a lot of issues out into the open and giving us an opportunity to really have a very frank exchange and a very direct exchange about a lot of issues I did just want to pick up we've discussed some of the issues that were raised in the recent interventions, IMPC codes and Vincenzo's point there is an obligation to carriage in the UPU that you do have to deliver but as David has pointed out there are exceptions and I'd point to the ETOs where we're separately discussing what the UPU's policy on ETOs should be and we heard the presentation yesterday I think that member countries should retain the right to determine how ETOs are handled but I wanted to come back to another point that Vincenzo made about basket one and that being where we can agree that we should focus our efforts and go to the congress with that and I just wanted from the perspective of the task force to urge that work continues and Oleg had a very constructive suggestion about what some of our immediate future meetings could be devoted to because he does have a point that as I think about it our survey asked the question what benefits will you bring to the network I don't recall that we had a question about what are the specific risks and what are the downsides that you see but final point basket one Vincenzo indicated that these are products that are appropriate for opening and I just want to highlight yes the Istanbul congress decided that they should be opened so if we go to a congress six years later and say that we are agreed to pursue opening of products that we decided to open six years ago that's not a great signal so I think we've had a great exchange today we can continue to work on some of the other sensitive issues and in line with the suggestion that Oleg and others have made in the conversation I'll stop there but I'm sure we can continue at the at the reception and look forward to our deputy director general's closing remarks. Thank you very much Stuart and I.B. if we can please go to slide 74 we come to the part of the agenda where we receive closing remarks from our deputy director general Mr. Maria and Oswald so Mr. Oswald please if you would take the podium. First I would like to thank the panelists for their inevitable contribution to the meeting today in addition I would like to express my gratitude to Nermin Rash again, Samir who is online for their great facilitation of such an encouraging and productive discussion. Special thanks also go to the crying trio Siva, Altamir and Peter we had wanted this conference to be a platform for open constructive and engaging dialogue and this is what we have achieved but we need to move forward to do that it is important to be aware of the market around us which is evolving very rapidly with a lot of things happening outside the UPU therefore working out the best possible relationship between the consultative committee and UPU bodies is going to be critical which was one of the aims of today's conference. On that point we got some very interesting insight on how the CC could be better engaged with the other bodies of the union speak and to inform one another so that we can all work together for the good of the union meanwhile some speakers have reminded us of the importance of our critical mission of connecting citizens around the world UPU products and services are the UPU's tools on how we can deliver on that mission the ongoing shift of volumes away from UPU to commercial network poses challenges on designated operators it is no wonder that some of them express concern about opening up. In that connection interesting remarks were made about what could be a sustainable way forward for example sharing the obligation and creating an equal playing field among all players one critical aspect of the need to be carefully considered here is the universal service obligation the universal service is something that makes the global postal network unique and this uniqueness distinguish it from commercial networks designated operators fulfill this obligation and therefore a level playing field can only exist if due consideration is given to the challenges around the continued provision of a sustainable universal postal service on the other hand we heard some great examples of how private sector players are already cooperating with designated operators some private players provided DO's with critical transportation solution during the recent pandemic also I heard the successful partnership in which private sector players are handing over to the DO's their packages for the final delivery against market rates these two examples illustrate how we meaning the UPU can work on partnerships with the private sector that support the USO while covering the cost of providing that service these examples are encouraging and my point and may point us to Arias where we make the able to find possible win-win solution as some members mentioned there are also strong differences in postal economic development between designated operators we must take those consideration into account as we develop our plans for opening up of the UPU's product and services to avoid that any country, citizen designated operator or wider postal sector players is left behind dear colleagues we are less than one year away from the extraordinary congress in 2023 we need to well prepare for the congress with concrete proposals for member countries to make informed decision on institutional framework and access UPU product and services I applaud to you all for the high level discussion that's in a way huge improvement from the past I also notice that the usually quiet majority is vocal and I'm happy because of that speaking on behalf of the executive management we would like to make this organization stronger, better and sustainable if we can achieve this with enhanced CC opening up with your consensus dear members we will go for it also maybe the most important remark we are all really on a very different level of market development and market understanding and we need more discussion like this one open discussion honest discussion but above all very respectful let me finish with one short liner one liner give us direction dear members thank you very much thank you very much deputy director general and just before we close I'm going to give the floor to the CC for an announcement on this evening's celebration so please sir the floor is yours thank you Raj it gives me pleasure to invite you all to join the consultative committee reception and meet our newest members to celebrate today's achievements thank you and ladies and gentlemen just before just before you rise from your seats we're almost done 60 seconds I'll give the floor to Nermeen to say her thanks and then I'll close the session thank you so much Raj thanks for the panelists thanks for IP great support thanks for member countries who and the expert of the bolster network who joined us and for the interpreters for their kind support and we should please end the evening and looking forward for active participation and contribution to this important work thank you Nermeen thank you and have a nice evening okay so we're within 30 seconds what I want to leave you with is two thoughts thank you for your engagement we had an excellent dialogue we talked we had challenges and questions and issues that were raised but I want to encourage members to hear that over the next year as the deputy director general said and as the international bureau said we have an extraordinary congress and if we don't go there with proposals we're going to go to whichever country wins tomorrow the right to host the congress and stare at each other that's what we're going to do and we're going to have nothing concrete to approve so I encourage all of you to keep working hard keep thinking bring your ideas and with that ladies and gentlemen we bring this conference to a close thank you very much enjoy your evening


Welcome to Toffy TV, it is the start and 11th show for Southampton versus Everton three o'clock at St Mary's this weekend. Let's get into it, Jordan Pickford in goal. A lot of people, when I picked Pickford last week, were like, why isn't Lacylin there? Cos he's not basically. Pickford for me, still Everton's number one, don't think he did much wrong last week. Possibly could have done better for the Deli Alley goal, but I don't think we'd have a situation yet where he comes out of the team. Pickford in goal for me, right back Siddabi, still deserves a longer run in the team. I think he gives us more options than Sheamus at the moment, going forward. So, Jibril Siddabi at right back, left back Luca Dean, don't know right last week. I've seen a couple of things where he was giving man of the mat. I don't think he was quite at man of the mat level, but brilliant cross for the equaliser for Jeng Towson and had a decent game. And then the two centre backs for me, going with Yeri Mina, who's been Everton's player of the season as far as I'm concerned, and Mason Holgate again, done very well as a pair last week again. Potentially could have done better with the Tottenham goal, but otherwise very, very solid between them. And that's a partnership that for me should be allowed to flourish over the next few weeks. And Michael Keane will just have to buy his time in the field. Morgan Snidelin, back in. Obviously Fabian Delph, writer that's very doubtful by the manager, so at the time of recording this, don't know whether he's going to be available. But Snidelin, given he's the only real defensive option we've got, put him in there. And then Tom Davis and Alex Awobi playing further ahead of Snidelin. Listen, Snidelin isn't one of my favourite players, I'm not going to lie.  And if he's just allowed to sit and just keep things ticking over, we'll get the energy in the legs from Davis and Awobi. So that's who I've gone for. Left-hand side, he played with Charleston off the left in this one. Theo Walcott on the right-hand side in this one. And I'm going to go for Dominic Calvert looming through the middle. I think about Jeng Towson, obviously came on against Woffordad and Assist, scored the equaliser last week against Spears. But I just feel as though away from home, I think Dom, decent in the air, bit of pace about him and we may play on the counter-attack and he'll shoot us probably a little bit more than Jeng. And then Jeng coming off the bench with 20-25 minutes to go, might be a better option. Moise Keane is another one of thoughts about, but it just seems at the minute he's not ready to go through the middle. Although I think with a midfield tour of Tom Davis and Alex Awobi, he could be an option through the middle. But I'm going to go with Dom just because he scored a few goals and he's played there. So that is the start on 11. I've gone for. I'm quite sure there will be people screaming at this with different 11s, particularly the Snideland decision and maybe also the Dominic Calvert looming decision. But that's the team I've gone for this weekend and we need a win. So let's hope we get one. Make sure you subscribe, give the video a thumbs up and if you want more videos, get over and join us on Patreon. See you later.


Greetings, friends. This is SurvivalDoc. Today, I'm going to do a product review of the World Gone Silent Solar Power Kit from campingsurvival.com. Now, this kit is specifically for the biofang radio. All right. Now, what makes it different is the fact that it replaces the regular battery pack with this battery pack, which comes with the kit here. And this battery pack allows you to use triple-A batteries. These are rechargeable triple-A batteries. Six triple-A batteries. This kit comes with 12 batteries. I tried it in the radio. The battery pack fits perfectly, and it works perfectly. So, don't get this kit unless you have or plan to get a biofang radio because this battery pack is specifically for that radio. Now, what this kit does, it allows you to have an alternate source from your regular lithium ion battery, allows you to use rechargeable double-A batteries, and this kit includes everything you need to charge those batteries. All right. Now, what comes with the kit? In addition to this pack, you get 12 triple-A rechargeable batteries. You get this little battery charger. It's a USB battery charger. It fits either double-A or triple-A. You fold it up like that for the double-A batteries. Fold it down for the triple-A batteries. All right. It also comes with the heart of the unit, which is this solar power kit. It's rechargeable with microcrystalline solar panel here. What I really like about this device is it has 10,000 milliamp hours. That's 10 amps, which is fantastic coming from a device this small. All right. This uses the newer lithium polymer battery as opposed to lithium ion battery, and I've been very impressed with the performance of the lithium polymer battery. All right. Now, there are two ways to charge this unit. All right. If you open it up here, you see it has two USB ports, and it has this smaller port. The USB ports are for output. This one over here on the right is one amp. This one over here is two amp. I noticed that Manuel explained that, but they're not marked on here. So this is two amp. This is one amp. All right. You can charge it by plugging in your little USB device here and then plugging that into any USB port and plug it into your computer or whatever. All right. Now, when it's charging with the power, there'll be a row of four blue lights that'll come across here. All right. And if it's flashing, it means that it's charging. All right. And when all four, the four lights give you an indication of how much better power you have in there. All right. And they'll be one, two, three, four. When it's full, it gets to four. And when it stops flashing, it's fully charged. All right. Now, you can also charge it in the sun, of course. And as you can see, there's this little green LED light whenever it's charging in the sun like it is right now, obviously. That little green LED light comes on. All right. So you can charge it with either the sun or you can charge it with any USB. All right. Then to get your batteries ready for your biofang radio, you need to put them in here to charge them. The disadvantage to this charger, of course, is it only charges two batteries at a time and it takes six to operate this unit. And you take this thing and plug it into any USB port, including the one on this unit. And you can see when I plug that in, it shows all four. I don't know if you can see that, but all four lights are on here indicating that this pack is fully charged. So the disadvantage to this is you have to charge two batteries at a time. And so you have to go through three charges to get your six batteries for your unit. The other disadvantage is this right here, these red lights here, LEDs come on when it's charging. They do not tell you when the batteries are fully charged. They do not change color or anything like that. It's just continuously charged. They have to be careful not to overcharge your batteries. All right. So and the unit also came with this useful little manual.  I'm not too impressed with this. These little compasses right here are real cheap and they don't, they do work, but they don't work very well. But anyway, so that's that if you need that. So what the kit comes with to review is it comes with this 10 amp power unit with a microcrystalline solar charger. It comes with this charger USB charger plugs into any USB port charges to AA or to AAA. And it comes with 12 of these AAA batteries. And of course, it comes with a cord to charge this unit if you want to charge it by USB. And it comes with the power pack, which holds the six rechargeable batteries, which plug into the bi-fing radio and work like a charm. So I give this product a thumbs up from Survival Doc. This is Survival Doc reminding you, be prepared or be prepared to be fleece.


So I am Betty Keller from the Vermont Physicians National Health Program. I'm the president of the Vermont chapter. I'm also the co-chair of the Education and Advocacy work group for one pair of states. And I'm on the health care committee for the League of Women Voters of Vermont. And for full disclosure, I have absolutely a financial interest in Medicare, but so does every other American. So no American can talk on this topic if everyone with the stake is disqualified. This is important to all of us. It's been a public program and the Medicare privatization, which includes Medicare Advantage, which we've had for several decades, and Reach, which is newer, formerly known as direct contracting, are threats to seniors in the future of Medicare. You can find out more information about this and see updates at the website protectmedicare.net. So what is Medicare? Most of us know that health insurance is, it's health insurance for people who are over 65 or disabled.  So we'll look a little bit more closely at traditional Medicare. You can find more details at medicare.gov. But part A is the hospital insurance, and the vast majority of us have no premiums if we've been paying into it while we were working or if we had a spouse who was. Part B is outpatient care. In that part, you do pay premiums and you have a deductible and co-insurance. Part D is for drugs, is the mnemonic. So those are for prescription through a private company. The insurance is provided through private companies that are regulated by Medicare. Medigap is what people will buy as supplemental insurance to give them an out-of-pocket cap.  And so Medigap gives you a cap where after a certain point, you won't be paying any more co-insurance you'll be done for the year. And it can help with other expenses that aren't covered with healthcare that's not covered by traditional Medicare. Vision, dental and hearing are generally excluded from these and you can purchase those insurances separately if you wish, again, from private companies. So Medicare Advantage was developed as with the concept that value-based care would change the incentives so that doctors and at that time it was primarily doctors weren't incentivized to give more care than you actually needed to be able to charge the fees for the services they provided. And instead the idea was that they would be charged to keep you healthy. So it would get a monthly fee and that would pay for your medical care and then they would provide the care that you needed. And the program would also have to pay for the images and things like that. So they pay a monthly fee to the providers to, I'm sorry, Medicare pays a monthly fee to Medicare Advantage and the Medicare Advantage pays the doctor's monthly fees and they pay for the images and the other things as well for the seniors and those who are disabled. So it covers medical care A and B and maybe also D but not necessarily. It may actually cover dental vision and hearing as well and they are allowed to charge their overhead expenses and also to have profit that they can keep up to 15% total of overhead plus profit. So if we compare traditional Medicare and Medicare Advantage this image shows the doctor or other healthcare provider getting paid directly by Medicare. In this one, you see that there's actually in Medicare Advantage, there's a middle person between the provider and the Medicare program. So how do Medicare Advantage plans make money? The idea is that they are looking at ways to keep you healthier so you don't need to use as many medical services but they are allowed to keep profit and overhead. So whatever they don't spend on those medical services they're actually able to keep. So that's a dangerous incentive, to ration and restrict seniors care which do not exist in traditional Medicare. So where are the different places that they can make money? One way is to minimize the revenue that they spend on patient care and the other is to maximize the revenue that they get from Medicare, that monthly payment that they get. So we'll tease out a little bit minimum expenditures where they try to save money. They seek patients that don't use a lot of services and historically one way to do that was to put their signs up in gyms, for instance. So the adults who were healthy enough to go to the gym were thought to be maybe not as likely to use up as much healthcare services. They also limit the care available for expensive conditions so sicker patients believe. Like you may have thought, well, I'm pretty healthy, I'll take the Medicare Advantage program but then when you actually got sick it didn't cover you so well, so then you left. One of the ways that they limit the care is to limit the networks of the doctors and hospitals. So for instance, if you have a very expensive autoimmune condition and they didn't cover the rheumatologists that took care of the more complicated situations. They didn't cover the hospitals needed for the most expensive care. You'd have a list of hospitals that were in network but they wouldn't cover the ones that had the burn units or the more expensive cancer treatments and they didn't cover medications that are needed by the expensive patients. So even if it was not that super expensive of a medication but it was needed by people who tended to be more expensive they might choose to just not cover that. Then the other thing that they do is maximizing the revenue that they get from Medicare. So by up coding to make them look sicker than they are then Medicare Advantage could get a higher monthly payment regardless of how much care they actually received. So I'm gonna talk to you a little bit about coding. Medicare used to pay them just based on, they paid them Medicare Advantage plans the same amount each year for each person just based on age. So if you were older they would give more money per month to the provider. But as you can imagine some people have way more expensive conditions. So that was part of what was leading toward them, they call it cherry picking where they're trying to get the least expensive patients to take care of by advertising in the gyms. So now they introduced in 2006 these diagnostic codes for chronic illnesses so that places wouldn't be as likely to try to lemon drop get rid of them more expensive care for the care for the more expensive patients. So let's look at an example of the up coding. Well, here's the coding. You can see that the baseline previously would have been the 0.45 just based on age and then they added these other codes. So for instance, just obesity is not given a particular number on the score type two diabetes, you would get 0.104 in addition to the baseline fee that you got per month. Major depression, well, zero asthma was also zero when they don't give any more descriptors congestive heart failure was 0.323. So in this patient with these history of these conditions that Medicare generally would typically pay a Medicare Advantage plan $9,000 for the year to cover for their care. Now, what does the up coding do? If you actually specified that it was actually morbid obesity so it's over a certain amount of the body weight then it would be 0.273 instead of just zero. If you identified that they had retinopathy which is something in the back of your eyes then they could give you 0.318 instead of 0.104. For major depression, even just specifying one single episode of major depression and it was a mild depression. They still could give a 0.395 instead of just zero. It's like, how is that different? That's like the most mild it could be but by being specific you could get more. The congestive heart failure by specifying that it was class three then that you get 0.323. So if you see down the road by being more specific and trying to make the person look as sick as possible even if they were walking around and going to the gym for instance, you could get an annual payment up to $32,000 per year. So if a Medicare Advantage plan is making that much money you can appreciate why they would be able to afford to offer extra things on the plan like dental vision or hearing. Although there's another thing on why they can do that too with the federal government setting aside some money to help them with that. So people are living longer and less than half of them were choosing Medicare Advantage. So these corporations on Wall Street are looking to see how can they get profit for the rest of the people who choose to stay on traditional Medicare. It's just a big pot of money that they don't wanna let go. So what is Medicare Direct Contracting? When the ACA, the Affordable Care Act was passed in it there's a little clause that says that direct contracting entities would be able to do innovative programs and start up these value-based plans just with having the center for Medicare services has a unit that was created called Center for Medicare and Medicaid Innovations. And so that subset of the Medicare program can choose to agree to let a new entity provide one of these value-based plans. They call it value-based plans. So direct contracting is where an organization contracts directly with Medicare to provide these services and then that program was getting a bad name. So they change the name and a few features but it's really essentially the same thing to this other program called ACO Reach. So what are these programs? So say you signed up for traditional Medicare and you expect to see whatever doctor you want to see, you have a primary care doctor, you've known a long time when you travel to visit your kids or whatever, you wanna know that you can be taken care of in the nearest hospital without worrying about networks and you don't wanna worry about, oh, what if I cost more than I usually do? I don't know when I might get sicker. So I don't wanna have these narrow networks and type formularies and things of what medications are available. So say you've chosen traditional Medicare but you can be aligned to one of these doctors or you can be aligned to one of these programs if your doctor chooses to go ahead with one of these contracts and your doctor may not even have wanted to but they are employed by a hospital or a clinic that chooses to sign up for one of these and the primary care doctors have big incentive in areas where this is happening, everybody incentive to do this because they get paid a monthly fee to manage your care. So Medicare makes a monthly payment to these programs to manage your care and the money like in the Medicare Advantage, they can go toward Medicare, overhead and profit. So remember seeing this picture before with the middle person between the provider and the Medicare with these new programs you actually have private equity firms trying to get a cut from that middle person, that middle program that is making money off of the Medicare Trust Fund. So how do they differ from the Medicare Advantage programs? The Medicare beneficiaries who are in Medicare Advantage they chose that plan, they weighed the savings that they would have per month versus the risk that they got sicker and those who are in the put in the DCE reach plans did not choose them, they may have made specific points of choosing the traditional Medicare, they typically pay more than a thousand dollars more per year for the benefit. Medicare Advantage plans can keep up to 15% of overhead and profit, but the DCE reach plans can keep up to 40% if they are able to spend little enough on your healthcare. Medicare Advantage was approved by Congress and these DCE reach plans have not been, they were introduced as a possibility in that one law but each of these new plans that go in they have not met rigid criteria like Medicare Advantage had to. So why should we stop the direct contracting and ACO reach program? What is, what's the big deal that you're seeing more of it in the news as time progresses? The problem is that Medicare has listed on its website even that has a goal of transferring all Medicare fee for service beneficiaries as they say into a care relationship with accountability for quality and total cost of care by 2030. Now this is a radical transformation and that's just eight years from now that they want everybody who's in Medicare to be in one of these kinds of programs where there is an incentive to deny care to try to reduce the likelihood that you will get the more expensive treatments. So there are a couple of reasons and one is that it threatens Medicare's solvency like will there be enough money in the trust fund when we get there? And by having all this up coding there is a huge threat to the solvency. There would be plenty of money if there weren't the caps on how much can go into it from your income and if we weren't wasting money on administrative waste and profits. The other thing is that it threatens seniors' help and their healthcare choices. As we spoke about that when you're in one of these programs it can be harder to get the care that you need. So in the solvency issue you can see that in traditional Medicare there is only 2% spent on overhead and there's no profit. And so 98% of the care goes to patient care. The Medicare advantage up to 15% can go for overhead and profit. And the patient care will only be spending 85% of the money would go toward patient care. With these ACO reach entities they won't all get up to 40% but they have the opportunity to get up to 40% of their funds from Medicare going toward overhead and profit instead of going toward patient care. So how do seniors end up in these ACO reaches? Their primary care doctor or their doctor's employer will sign a contract with one of these reaches. It's also not clear but it may be that the managers of their retirement plan may sign a contract with one because these are innovations the plans aren't all the same as each other and things can change and we don't exactly know where things will go with them. How can you get out of them? Well, one way is to change your doctor but you'll recall that the goal is to have 100% of people on something like this. That means over time there would be no doctors who were not in them. Another would be to lobby your retirement plan to make sure that they know that you're looking at this and that you don't want them to sign up with them. But it may be more effective to work to stay out of reach than to try to get out once your doctor or plan is put in it. So to try to raise awareness among physicians to please not sign up for this and if your local hospital is signing up for it talk with them about why this is not a good thing for our community and for the public good. And the other is to try to stop it so there doesn't exist so they won't be signing up for it. Why isn't Congress trying to stop it? Well, one thing is that until recently most of Congress had never even heard of direct contracting or ACO reach. In January, 54 members of Congress sent a letter to Health and Human Services demanding that we end the program. And the process of getting those numbers of Congress to sign a letter was an educational tool so they even will heard about it. And now later in January, maybe it was February they actually reviewed the program, realized that it had a real marketing problem that people were getting angry about it. So they said that the DCE program will end at the end of this year. So no new ones are signing up for that and they're gonna start this ACO reach program instead as of January 1st. So anybody who wants any private equity firms that wanna get involved in this they can be going through the process now but not start until January. And there's so much money at stake that they are fighting hard to protect their opportunity. They make profit on this. So what can we do to stop this on May 23rd? On that is a Monday at 1 p.m. there'll be an online Zoom type of program turning up the heat on direct contracting and reach summit. So so far PNHP and allies like Social Security Works have been focusing on trying to reach out to legislators. And what they're hearing is that, oh well, we're hearing some complaints about Medicare Advantage but nobody's talking about DCEs, nobody's worried about them. So what we're doing is reaching out to more individuals and telling people, tell your legislators that they don't think it's a problem, tell them it is a problem. They need to be looking at this now and get this stopped. So we're hoping that as many people as possible will attend the summit, spread the news, tell other people about it. It'll only be about five minutes worth talking about what DCEs are. And then after that we'll be talking about what do you do about it? How can you become active to try to stop this program? For individuals, you can also sign up and share, sign and share the petition to stop Medicare privatization. And you can find this address again on that webpage I had shared earlier in the beginning of this presentation. You can also write a letter to the editor in your local news outlet. And again, that's protectmedicare.net to get guidelines on what to put in your letter. If you belong to an organization, you could chat with the rest of the board or if you're not on the board, then talk with the leadership and ask them to sign on to the ACO reach and Medicare privatization petition against it. And also try to get more members of your organization to sign. So again, that's the webpage protectmedicare.net. And that's the end. I have some extra slides if they happen to match up with what people have questions on. So we should, let's see. So we're allowing participants to unmute themselves. Good. Okay, so first I'd like to ask folks to ask questions that they have. If you have comments that you wanted to share, if you could wait on that for a minute to see what questions people have first. So if you have a question, you can raise your virtual hand if you see at the bottom it has a reactions and you can click on that and then see the choice for raising your hand. But since we're only on one screen, I can actually see if you just raise your hand. Rebecca, do you wanna unmute yourself? Two part question. What percentage of Vermont providers are linked to the ACOA reached and how do we find out who they are? Well, thank you. Actually, I'm gonna let Ted talk about that because Ted Cody is my secretary of BNHP and he's looked into this a little bit more and Marvin Malek is here too. If you could unmute yourself, Marvin, then when you have something to add, you can help out too. He's the past president of BNHP. So Ted, do you wanna talk about that? Thank you, Rebecca. I'm a retired internist and have occupied myself with some of these issues. All my patients were of Medicare age, put it that way. The information is that in the state of Vermont, only 13% of all Medicare recipients are on Medicare Advantage. That's lower than the rest of the country, but the local insurance companies are starting to market much more heavily. There is one ACO reach practice in the state so far. It is located in the Burlington, Essex area. It's called Evergreen Family Practice and it subscribes to an ACO reach corporation called Clover Health, which is a organization that has promised physicians in Vermont up to 40% improved profit per patient. And the way that they're going to do that is they have a computer program which has a nice cozy name to it. And when you go to, if you visit one of these Evergreen Family Practice physicians, the first thing that will come up on their computer screen is this computer program developed by Clover Health, which by the way is all venture capitalists has nothing to do with health. And the purpose of that program is to achieve the most efficient degree of up coding as Dr. Keller so clearly set out. In other words, if there's something that might make the company more money, the computer will tell it that. It's kind of hard to tell whether the doctor is treating the computer or whether it's treating you. But that's the answer in Vermont so far. I'm sure there'll be more. Did I answer your question? Right, so we only have one. So when Vermont P&HP spoke with Senator Leahy's staff a week and a half or so ago, they were, well, yeah, nobody really cares about it. It's Medicare Advantage. We're getting way more calls about Medicare Advantage now than we used to, but they aren't hearing from DCE folks yet, because it's just so new. Marvin, you wanted to share something? Yeah, I didn't want to interrupt you. Finish what you're saying. Well, I did want to also just say ACO Reach, just to give you the name, ACO is Accountable Care Organization and Reach is Realizing Equity, Access and Community Health. So basically, the direct contracting entities was too easy and a target. So they got together with some PR people and said, well, should we call this instead? But the program is very, very similar. There are a couple of things thrown in like you can actually make more money by documenting the data of how many people you are surfing who are from marginalized populations, but you don't actually have to improve their outcomes or anything. You just have to document that they're in your program and you can make more money. Yeah, Marvin, go ahead. During this earlier in the talk, thank you, Betty. It's a great talk. Earlier in the talk, Betty mentioned that the goal of this autonomous center within the Medicare program is to enroll every single person in Medicare either into a Medicare Advantage plan or in one of these deals. And there's actually a variant of ACO. They're largely similar. That we have an heavy dose in Vermont, which is the old kind of ACO. Structurally, it's not fundamentally different from the ACO reach, but pretty much everybody who gets care at UVM or one of any part of UVM's empire who's a resident of Vermont is part of this other ACO that's been around for a longer period of time. It's called OneCare. And OneCare, as is the case with the rest of the new reach program and the Medicare Advantage plan, they all have not saved money for taxpayers, quite to the contrary, they've extracted money out of the Medicare Trust Fund. And in fact, there was an article just published yesterday in the Journal of the American Medical Association, very prestigious journal, pointing out that the Center for Medicare and Medicaid innovation that's corraling, that appears intent on corraling everyone in Medicare into one of these deals, these DCE or reach deals by 2030 that the program is a remarkable failure. They've had 50 different variants of this. And out of 50, only six of them have actually even saved a little bit of money for the Medicare program. And if you figure it's either gonna save money or not save money, it should have been that on a random basis, 25 of them should have saved money, but it was only six. So it seems like the model, as Betty pointed out, the model is so heavy on administrative, on gratuitous, unnecessary administrative effort and cost and numerous, numerous employees that the program, and then leaving aside all the profit that the program, you can see why the program is losing money for Medicare. You can make an argument that the private equity firms like the one that we have in Vermont, this Clover deal, Clover Health, that it's probably worse, they're probably more mercenary. For example, United Healthcare, the nation's biggest private insurer, which now has ever bigger inroads in Vermont, they're absolutely mercenary about denying care. Like we've had a bunch of patients where I work at Springfield Hospital, but we don't get paid. They just deny payment for the hospitalization. It's unbelievable, it's just unbelievable. Like if you're in Medicare and you get hospitalized, there's a book that tells them how quickly to dump you out of the hospital, how quickly you should be discharged, like one day, two days, three days and the book has this formula for each problem like hip fracture. And, but the program is based on the idea that you have a dozen family members at home, all of whom are muscular, all of whom are very medically sophisticated, who can totally take care of you. And if that's what you have, then yes, you can go home one day after a hip fracture, but not everybody has that waiting for them at home. And it's like unbelievable. And if you fall out of those criteria, you just don't get paid. And this is in common between the Medicare Advantage insurers and the private, the DCE and reach ones. It's all the same. It's very demoralizing. And to work as a doctor and this is, it's just very demoralizing. We try to do our work. And then even if we have a great outcome, not even to get paid is just very demoralizing. It's disgusting. But I'm not saying that we're worse off than the patients because they're being hurted into managed care that they don't even know about. And I just think that's appalling. I just think this whole thing is appalling. And I hope that all of you will write, even though Bernie Sanders has signed the letter and he's on the right side of this. And so is Peter Welch. Write them anyway. Tell them to do more. They need to do more. Lay he should do something. Lay he should go talk to Biden. Tell them to get this under control. It's ridiculous. Sorry, I'm sorry to talk for so long. Marvin brought up a good point. Oh, let me hear from Mary Alice first.  Mary Alice, you're muted. Yeah, she's trying to find it. Well, Mary Alice is looking for that. Oh, I'll go ahead. Oh, you still haven't figured it out. It's in the lower left generally, if you bring your mouse down to that area. There you go. Are you? Yes. You get it. I have a new Chromebook. It's a new Chromebook. And it runs just a little differently. I've been following a lot of this and I've been following in the legislature. I still want to know what is value-based care because they were going to have all kinds of money they were giving to the Green Me Out and Care Board to find out about value-based care. The other thing I wanted to say that I do have UnitedHealthcare. I've had it for years and years and I'm grandfathered into something called the Plan J. I pay a whole lot of money, like $234 a month for a copay, and they're raising it again in June. So they're telling us that the only thing UnitedHealthcare is raising are people that aren't on Medicare, but they are raising it for those of us who are on Medicare also. I have to find the letter. My filing system is terrible, but somebody at Digger is going to be doing a little research on that. So I'm hoping that'll get figured out, but I just wanted to mention that. And value-based care, what is it? And why can't we do fee-for-service? So that's a really good question, Mary Alice. So the concept behind value-based care, in theory, it sounds good. Oh, well, if you get charged fee-for-service and the more services you give, then the more you can charge, make more money, and the more things you buy, you sell them, like maybe medical devices, wheelchairs, braces, whatever, the more things you sell, the more money you get to make, right? And the idea in value-based is that you remove that incentive, instead of getting paid for every single thing, you get one fee, and you try to manage their care and reduce expenses by not ordering duplicate tests, for instance. So if you have one managed care organization that centralizes all of its studies, and say you have an x-ray done by your primary care physician at one hospital, and then refers you to a tertiary care center where there's specialists, and they want to repeat the x-ray because it's not their x-ray. Then you've played duplicate services, and if you're in a managed care program, they'll figure out how to use the first x-ray. They won't repeat that. But the reality is that we don't need to have those kind of motivations unless you have an oversupply of doctors because you don't have any incentive to try to see people more often if you already have a long waiting list, and patients don't typically want a second x-ray. They don't want to take more time off from work to go get something that they don't actually need, and they don't want to take more drugs than what they actually need. So where is the overutilization coming? When they've done studies, there are a couple of things in some cardiac interventional procedures, for instance, that there are more being done than is maybe healthy for the public. And so we should attack those specific things. But overall, when you compare Americans to people from other countries that have healthcare systems that are not based with any profit in them, you'll see that we see doctors less frequently, we get hospitalized less often, and we get discharged from the hospital faster. We are not overutilizing care. So the paradigm of thinking, oh, we need to get rid of fee for service is just really a false notion that if you had an oversupply of everything, then you'd have to figure out how to reduce overutilization, but we do not have overutilization right now. With the value-based care, the idea has been that, oh, we'll get more value, more bang for our buck. You'll save money on the healthcare, but the only way to do that is to either have people use less of it or to not get the people who need more care. I mean, basically your motivation is to try to get people who don't need much care. So when they say, oh, we want to have value-based programs that either improve quality without increasing cost or reduce cost without reducing quality. When you say that, you say, well, right off the bat, we don't have a lot of places to cut from if we only have a 2% overhead and we're not overutilizing. Medicare is not overutilizing and it's only 2% overhead. So how where are you gonna cut from that? You can figure out specific things if there are overused things, you can require that specialists use the first X-ray and not repeat the on on their own machinery. You can do little things like that, but that doesn't require overhauling the whole system and overhauling the whole system will not improve it. So in the law, it says that it's not supposed to increase costs, but we're not seeing, they're not showing us the data to show that they are improving quality and keeping the cost the same or cutting the cost without harming the quality. We're not seeing that data. Like last week, there was something in the New York Times, Marvin mentioned something that came out today in this medical journal. So we're seeing things that contraindicate it, but contradict it rather, contradict it, but we're not seeing data that supports it. So I wanna see the numbers and it doesn't make sense to me that it's actually realistically possible. So I really wanna see the numbers of how they're doing that. One thing is they might not be showing the waste that happens in hospitals if they're only showing how much it costs from the provider's point of view. But if you look at how much it costs for hospitals to deal with this, you would immediately be seeing that this costs more. Now, if somebody had their hand up, Mary-Elser. I wanted to mention also the auditor of accounts did a study about that and found that it actually, it was not one care that was saving money, it was other parts of the state where there isn't even a one care.  Yeah, yeah, agreed. Can I say something? Yeah, if I could just reinforce what you said, Betty, in a slightly different way. The idea of value-based care is if you pay a physician a set amount per patient and that set amount is independent of how many visits and so on and so forth, then the physician, his or herself, will choose to not do anything unnecessary and will somehow make things more efficient in the long run. Two caveats to that. Number one, no physician has 100% of his or her patient patients in these value-based care arrangements. So it's impossible to give one standard of care to your fee-for-service patient and another standard of care to your ACO patients, for instance. Second, and let me be a little cynical about this. The way we measure value is by means of roughly 50 criteria in the case of one care. In other words, have you been able to get your diabetics to a lower average hemoglobin A1C level? How many rectal exams did you do and this kind of stuff? But in reality, the physician, the practice, the ACO, the DCE, the reach, whatever you call it, does not get penalized unless they come up on one of those 50 criteria. In other words, you can cheat the patient however you like as long as you don't get caught by having a lower average of one of those criteria. That's what it boils down to. Sorry to be so cynical. It's a really frustrating thing for providers because you're trying to keep your practice open. You're trying to stay in business because if you can't afford to stay there, then your area will be underserved, right? Especially if you live in like a rural area of Vermont. But the motivations are just, if they just would improve the reimbursement instead of having to go through all this other stuff, doctors would have more time to talk to each other. They wouldn't have to be depending on a computer telling them something. And you wouldn't be paying extra people to go through the charts and figure out where they can save money in all. Marvin? I just wanted to amplify what Betty just said. Doctors, so the doctors this is gonna impact the most are primary care doctors, correct? But they account for tiny fraction of overall spending. The specialists who are earning hundreds of thousands of dollars, they're gonna be fine. I mean, I think the goal of the program was to somehow decrease overall spending but why you're picking on the primary care doctors is beyond me. If somebody needs an operation because they have colon cancer, being in an ACL reach is not gonna change that. They still need the surgery. And I think the biggest fundamental problem is there's no evidence that we're providing a lot of unnecessary care in the United States. And also there's no evidence that even though there are variations in the amount of care that's provided in different counties and different parts of the country, they've actually experimented with changing payment models and it doesn't affect it. That our doctors decisions about what treatment to give is pretty much always based on what they think is appropriate and necessary and what the patient wants done as well. So, and that's really how it should be. But going back to primary care, so primary care doctors are paid the least pretty much of all the specialties, pediatricians especially. And so the one in Vermont, the evergreen practice that Ted was talking about earlier, which has sites in Chittenden County in Charlotte and Williston, they are trying to stay independent of UVM. And so this is a scheme that every time they activate the Clover Assistant, which is the software that Ted was talking about, they get $31 from Clover just to activate it. And the Clover Assistant software program in their computer queries the doctor to try to get them to elicit lucrative diagnoses, diagnoses that'll increase the up coding and allow Clover to extract more money from the Medicare program. So in the sense the $31 going to doctors is a kickback for a scheme to extract more money from the Medicare program. And so they're putting doctors in this position instead of paying primary care doctors an amount of money that would make it a semi competitive specialty compared to neurosurgeons and ophthalmologists, they put us through these shenanigans where we got to start logging into the Clover Assistant and interact with it. And supposedly it takes five minutes. That may not seem like a lot of money, but if those of you who walked into a doctor's office and had a visit, how many more than five minutes do you get with the doctor? Like you get 10, this extra software gets five and their own software, which they still have to deal with gets a certain amount of time too. So this is directly bad for patient care because it's a diversion. The doctor's not gonna be able to schedule more patients. The doctor's trying to get the $31 each time somebody and enrolled in this Medicare who goes to Evergreen in the Medicare program walks in the door. So it's a big diversion, but it's basically a scheme. It's a kickback scheme from the doctor's point of view. And I just think it's reprehensible that this is what primary care doctors have to do to try to stay independent of one of these monster organizations like UVM or Dartmouth. You can't maintain autonomy anymore. I see Mary Alice has another question. Does anybody else have a question they would like to raise? If we go ahead, Mary Alice. Well, I know the May 23rd meeting is supposed to talk about things that we can do, but I haven't had any luck and writing to my congressman. They called me back and talked to me about media and talked about other things. They tell me all these wonderful things, but they don't ever mention healthcare, even though that's what I'm asking them about. And I'm just wondering whether... I had read some stuff a long time ago because I've been doing some research too that back when CMI was put into place the Congress doesn't have any more contact with CMI. And how can we convince them that they need to get involved? Is that what the May 23rd meeting is gonna talk about? Yeah, the May 23rd meeting will be talking about what individual citizens can do to try to make a difference. But I can tell you a big part of it is reaching out specifically actually to Senator Leahy's office. So he's in office for one more year. He's not running for reelection. He's gonna retire, but he's there for this year. And right now, there's a lot happening on this. This program started, it was put into the ACA law during Donald Trump's tenure. They started to do a few of these programs. You had to have a program for these direct contracting entities. They had to be built on a pilot done somewhere else. So OneCare is actually a pilot for these things, which is why CMI has been working so hard to make sure it works, you know, or that it's sustainable or whatever. And when I say it works or it's sustainable, what I mean is that it will meet their criteria for being able to base a direct contracting entity on its model, not that it's actually sustainable for us financially or anything. But anyway, so and Senator Leahy's staff said, we're not hearing anything about that. Nobody's talking about it. We, you know, we'll keep our ears open, but they weren't taking an active role. The thing is that our legislators don't have to pass a bill on this because it's entirely under the auspices of the executive branch. So if Secretary Becerra were to decide to stop this program, it would stop. He could just like say the word and it would stop. He's not gonna do that unless President Biden is on board. And President Biden hasn't seemed to take any notice and made any comments about this. And of course, we know that he's been totally behind the support of the Affordable Care Act and has not wanted to pursue a single payer type system. So he's just thinking in terms of, oh, well this within the ACA and I'm supporting the ACA. But we need to let him know this is not a good part of the ACA. This is something that should be changed. And so we want to have people reach out in ways that will change the deciders. You know, the decision makers minds and I don't know what that is. I'm looking forward to finding out on May 23rd what they're recommending. But in the meantime, I know that contacting Leahy's office, Senator Leahy's office and asking his staff to do what they can to put pressure on Becerra and on President Biden saying this is the bad thing for our Medicare programs. It is robbing the trust funds and it's harming seniors' health and it's harming their autonomy. When they chose one kind of plan, they decided to be in traditional Medicare and they're taking away their choice. That's just, that's reprehensible. And so stop it now. We don't need to wait for any laws to be passed. There could be a law passed to also require that it underwent more restrictions and more overview. But trying to get anything through this Congress right now, I mean, seriously, when there's an executive branch decision path that could work instead, it seems like that's the way to do it. And we should be doing it now. So the current direct contracting entities are only through December 31st and the REACH program, they're applying, the companies are applying to become those kinds of programs but they can't start until January 1st. Basically kind of a little hold on it. Margaret, you had a question? Margaret had, yeah. Thank you. My question is, you mentioned the secretary's name. Can you say that again and maybe spell it if we need to? Are you able to see the chat? So it's Secretary Becerra. Becerra, okay. V-E-C-E-R-R-A. All right, great. Thank you. And she's the secretary of health and human services. Is that? So he is the, yeah. He is. Secretary of health and human services, right. Okay. Thank you. So I'm also putting in the chat, protectmedicare.net, that's that website we were talking about. And on there, you can find all the links for those other like the petitions and stuff. But if you belong to an organization like community of Vermont elders or other senior groups, if you belong to advocacy groups like rights and democracy, if you belong to V-PURG or something, if you belong to organizations that work out for the public good, then you could also ask them what they're doing toward working on opposing these and stopping them. Any other questions or comments? Rebecca. Just a quick question. The Vermont council on aging the area offices, are they reaching out to Becerra and on board as well? So they have huge concerns about it. I was just speaking with someone there who said that they have had a 40% increase in complaints about Medicare Advantage because of the increase in marketing and that we are having more people in Vermont on Medicare Advantage now. We went from four plans a couple of years ago to eight this year. So there's like a doubling in the number of plans here. But she said that they're part of their funding actually comes from health and human services. And so if it's a current policy of health and human services, they cannot vocally oppose it because of their grant funding. But I mentioned something too, they're expanding use of... Mary Alice, your voice left us.  Oh dear. So somebody's expanding something. Can you hear me? Oh, I heard that now. Now you're back. It's, I have a very bad internet connection, but that they're using home health and they're using SASH, we're getting all kinds of contacts in the home. And that's wonderful, but it's like they're using that to save money so that you don't go to see your doctor or see a provider who really can maybe help you. So home visits can actually be really wonderful. They can provide an actual visualization of what the person is living in. So if they're, for instance, handicap, what kinds of barriers do they have? So there are huge benefits to having a home visit. It makes it easier on the patient if they're in a lot of pain, if they're nauseated, you don't want somebody throwing up while they're trying to drive themselves to the hospital or something. So for instance, in France, they have like teams of people that are running around doing home visits all the time and it's not thought of as being like a detriment or anything. In the UK, they have people who are set aside every day out of their primary care providers. Most of them are scheduled to see patients and somebody is scheduled to go out and see people who are too sick to come in. You don't want them sitting in your waiting room and infecting other people or you don't want them throwing up in your office. So they pay home visits there. So there can be benefits that way. On the other hand, some of these organizations, these like direct contracting entities, will actually pay people to go in and do home visits not because it was convenient for the patient or helpful for the patient anyway, but so they can go and look over on for clues about ways that they could up code.  Let's see if we can make anything out of that since I see that in your bedroom. So they're actually, they're paying people to look for ways to up code. They're spending healthcare providers time looking for that instead of looking for ways to improve your healthcare and give you a better quality of life and all. Yes, I'm 85 years old and I have a list a mile long of all the different things I have. Some of them are things I had when I was a child. Like I used to have ear infections. So now I think they think I'm hard of hearing. You know, how can they get away with that? Well, problem-oriented medical list is actually helpful for many things, but yeah, when you're taking things off of it purely to up code that's not good for patients. So thank you all so much for your time. I appreciate your concern that you came to hear about this and you can find more information at that protectmedicare.net. If you're interested in the May 23rd, does somebody have a link to throw in the chat here before we close out? I don't. Well, thank you so much to Orca for reporting this. I'll stay on for a minute and see if there are some things to pop in the chat for you all, but we'll wind up and thank you so much for your time and your attention. And I hope that you can help us in opposing this privatization of our highly effective and much beloved public health program Medicare. Thank you.


Hi, I'm Lisa Peterson. I am the extension livestock and extension beef quality specialist at the Central Grasslands Research Extension Center, which is NDSU's facility in the south central part of the state near the town of Streeter. Today I'm going to talk to you about five tips, beef quality assurance tips, to help you improve your cow herd. Most of these tips is to develop a herd health plan with your veterinarian and other management partners like your nutritionist or county extension agent. Within this herd health plan, we would encourage you to talk about herd goals. What are the things you want to do with your herd? Is your goal to retain ownership on those cattle through slaughter to sell replacement quality heifers, to sell purebred bulls? What is the goal of that herd? Next, we would like to identify any issues or problems that the herd currently has or are imminent. We would call those emerging issues. Next, we would like to develop a prevention plan for those issues and then a treatment plan for any issues that may arise. And finally, develop an overall management and marketing plan. The second tip is to keep good herd health records. These are so vital to identify any issues that are within your herd and help you market your cattle better. These should include a vaccination record, should also include an individual treatment, along with a group treatment. So anything like an insecticide that you would give for lice prevention, for example, we would like to keep in group treatment records. Then we should use those records to help us market our animals and we should look at any diagnosis or testing and results that have come from those.  I call this strategic culling, culling beyond the opens, olds and honorees. And so I encourage producers to keep record and to measure and record utter quality, foot quality, disposition, body condition score, and mouth. Mouth those cattle occasionally. So I encourage producers to look at the feet and udders at calving time. That's an easy time to keep those records when you're already writing in a calving book, some calving details. Keep those body condition scores at calving and then at timely times throughout the year.  So probably either at turnout time in the spring or at winning time in the fall when we're already moving cows through a working facility. Use those records to help you ultimately cull your animals to improve your herd. And what I would like to say is strategically target those animals for culling. Identify those cows before you turn out bulls that you would like to remove from your herd. Then strategically do not place them with a bull. You do not want them bred. Wean those calves early and you can market those cows in July or August typically when you might be able to reach what we would consider to be a historically higher market cow or cull cow market.  Look at those cows throughout the year. Start checking for things like lameness that's going on in the herd, cows that are becoming thin, maybe have some disease issues. And so monitor and manage those and market them in a timely fashion.  And finally stop the truck. Before you market animals, check all animal health records and make sure that all withdrawal times have been met. Be sure that all of your animals are a body condition score two or higher. Be sure that all animals can stand and walk on all four feet and legs. And ask yourself, would I feed my family what I'm going to load? And if any of those are answered, no, don't market those animals. And finally, don't forget to shut the gate. So with that, I'm Lisa Peterson, the Extension Beef Quality and Livestock Specialist for NDSU Extension at the Central Grasslands Research Extension Center.


So the U.S. economy may be on the verge of a slowdown as investors closely monitor quarterly report cards from big names including Facebook and Apple. We bring in Lou Bassanis, the founder and chief analyst of disruptive tech research. Jonas Ferris, co-founder of maxfonds.com and a Fox Business contributor. And Melissa Armo, the founder of stocks. Swoosh. Good to see all three of you this morning. Jonas, I want to begin with you. The Walsh Street Journal did a survey and they find that this time next year GDP growth will slow to 2.3 percent. We just got a read of three and a half percent. Do you buy what the journal is predicting? That's again a survey and 2.3 is not that bad. I think there's some fears that there'll be a recession by late next year. So this would be perfectly fine. And that a slowdown like that is not why interest rates are going higher. It's not why people are selling tech stocks. That's for sure. I think there's general fears about the market that exceed what that is. But there is definitely a sensation that this many years into an expansion, this hot of stock market, this many years it's eventually going to end. It's no one's fault. That's what's going to happen at some point. Melissa, do you think the market is already pricing in the thought that we could have the start of a recession next year? No, I don't think that at all. The market based out for a good better part of this year. And that to me, the one I look at it technically speaking is a rest period, a rest period to break out higher. And in fact, we did do that. We broke out and made brand new Altem Highs right after that rest period in August in the Dow. And we almost hit 27,000, which is a big number. So I see the end of 2018. My projections is that we closed strong by the end of this year. And we'll see how we act in 2019 and 2020 going into the election. However, that being said, it really depends a lot on quarterly earnings. We're getting into a critical week here for the market. Facebook reports, Apple reports. And I do think the market could recover from the sell-off it's had in the last two weeks if we get some good news out in these reports by the end of this week by Friday. We could have a strong rally in the market by the end of this week. I want you to keep talking, Melissa, because as you're speaking, the S&P just went from negative to positive, looking at futures in the Dow. It's down only 11 right now. Lou, what do you make of Facebook's impending earnings report? What do you expect from them? Listen, we are in desperate need of a tech savior and Facebook's not it. I think the last time we talked, Facebook's been in the penalty box. I mean, they are still repenting for their sins of the past for violating user privacy and data. I just, you know, I think what's baked into the share price right now is a disappointing report. Profits are supposed to be down about 9%. If it's lower than that, look out below. We're going to be praying for Thursday to get here and Apple to save us, because if Facebook can't do it, Apple's going to have to. Oh, and Jonas, do you expect Apple to save tech? And I also wanted, Jonas, to get your opinion of the Wall Street Journal report this morning that billions of dollars in fines from Asia and Latin America, I shouldn't say fines, I'm sorry, taxes can come on these big tech giants because they would look to tax their revenue instead of their profits. The global, the first question, the global tax and regulatory changes happening to tech stocks is one of the reasons they're not doing well right now. They've gotten kind of an easy ride for several decades, both regulatory and in taxes, the way they get to shift earnings around. Those glory days are coming to an end very quickly. As far as what's going to save us, we've had a lot of great earnings reports so far this quarter. It's not saving the slide. Investors are scared that the end is here and that it's going to take more than just one tech company's good earnings. I would expect Instagram to look to look good, Facebook part of it, not so good. Apple, they can sell expensive phones in the few days that they had of the new phone. It'll help but it's not going to turn around this slide and tech stocks. It would take more than that, a real shift in confidence. Melissa, do you think these worries that are impacting stocks are spilling over into other asset classes like commodities, like currencies? No, not necessarily. I mean, the tech stocks have always been in their own separate bucket. And earlier this year, I said Facebook is even in its own different bucket now because I really don't look at that when I look at Apple, Google and Amazon anymore because the stock now at Facebook is in a downtrend. These other stocks are in an uptrend. So when you look at what's happening in the overall world and you look at the US dollar, the US dollar is getting stronger and stronger and stronger. And I just think we're a long way off in a recession. I know interest rates are rising, but part of that is because the economy is so strong and there's just no reason to think that the economy is all of a sudden going to be strong and then not be strong. We have had good earnings like Jonas said. And even though some stocks have reacted not as positive as we would have liked in the earnings, based on as far as the stock trading, they still have reported well. I truly believe that Apple is the one to watch this week. And here's why. Apple is the strongest stock right now in the market. Apple is barely off the highs. Even right now you're seeing this morning it's up in the pre-market, 218. Previous high in Apple was 233. And the market is nowhere near the highs right now. And Apple is close to the highs. Apple is the strongest stock in the market. And if they report well, it's a buy. Yeah, but everything going on with China as we wrap this up, Lou. You have the final words, Lou. What do you make of Apple? I'm sorry. Look, I think sentiment's soured. We need to see some risky behavior. I'm looking at the Russell small cap index and the NASDAQ biotech index to see that sentiment change. And if investors are coming back in, there's some companies in the small cap space that are reporting earnings as well. And I think that has the possibility to turn things around along with Apple and a good report and higher ASPs for the iPhones. Lou, Jonas, Melissa, thank you. Thank you.