I personally didn't know that it's a whole specialty on its own. What is it about? Why we need to take keen, you know, focus or interest on this particular matter? How exactly are we supposed to handle different situations where we have wounds and everything for us and for people around us? Welcome, Dr. Hari. Thank you. Thank you so much. Glad to have you with us. Glad to have you here as well. Ah, so like I have just said and I had told you before, I didn't know that there's a whole, you know, it's a whole specialty that a doctor can specialize in, you know, wound treatment. Tell us a little bit about it. Actually it's an open forum for nurses and doctors. All can specialize, can advance their programs into wound specialties. So it's a science whereby you study more about tissue viability, how tissues heal, making wound heals heal quicker and such. So it's a very interesting docket just to observe wounds heal quick. And like all the methods used whereby you find someone will end up with an amputation or will end up with some very life-threatening situation, now things have been made simpler. Just the same specialty, it has really improved a lot on the care. Okay. And as we go on, you will tell us, you know, what new technologies or what new science has been implemented to improve on this care, particularly care. For starters, tell us the different types of wounds that are there and the best way of treatment for them. This is a very broad question. We categorize wounds, okay, when we're talking about different types of wounds, those that falls under trauma, for instance, cut, we have incisions, surgical and both, maybe from home we've cut ourselves at night with a knife and so forth. Those that falls under burns, I'm very sure you talk about burns, everyone think about fire and something called, this is also burns from chemicals, from radiation, from electricity, even there is what you call negative thermal effect whereby you've been subjected to extreme cold temperatures, you can still have a burn, like frostbite is a kind of a burn, but from a negative thermal effect, then there are those that are caused by predisposed commodities like diabetes, maybe find a low immunity, the vascular conditions like this venous ulcers, arterial ulcers, those are caused by vascular commodities, then we have those that are caused by auto or immune deficiency, like get patients with HIV, some of them normally end up with some funding and healing wounds. So you can categorize according to many ways, so there is burns, we have trauma, those that falls under predisposing comorbids, then we have also pressure ulcers, this is very common, those patients lying in one position for too long or the turning is a little bit difficult, they end up with a pressure ulcer as well, those are type of wounds. Okay, pressure ulcers, that's the first I'm hearing of it. Commonly people know it's bed sores, you've heard of bed sores. Okay, all right, okay, learning. Okay, for all these categories, is there a specific treatment type for let's say burns for the trauma type of wounds? Now that is what we mentioned now, the science of wound healing, the phases that normally observe, some wound follow a specific path of healing, so that is what we manage. For instance, those that are caused by trauma, you find that a wound bleeds, then from bleeding, so this specific, okay, let me don't use so much every time, these are path that they follow to heal. There's a hemostatic phase whereby the body initiates a process to stop the bleeding, then there's an inflammatory phase whereby the body fights back, there is those bacteria introducing the wound or mediators which need to start to initiate growth, those growth factors, that's the second phase, the inflammatory phase, then you have the proliferative phase whereby tissue starts to germinate and grow, then after that we have the maturation phase at the end, already tissues have grown, now they mature up or as formation of scar is being reduced to normal skin, so all wounds have a specific path they follow, so that is what we normally manage, that's why we talk about wound care being a science, so you observe the science, you treat it according to what the course take, in some modules I was talking about they wound speak to us, what it needs is what you give, for instance if there is an infection, treat the infection, if there is non-viable tissue, treat or remove the non-viable tissue, if the wound is healing promote more healing, yes. Okay interesting and you've mentioned a module, so do you teach on this also? Yeah we've partnered with our association so that we can be able to pass on this message across to healthcare practitioners like the national nurses association of Kenya, we reach a lot to nurses and doctors who are interested in this program say come on board and we just pass on the knowledge, it's something which is very key, the other thing that we do, okay I'm an executive member of the foot and limb group salvage, being there we tend to, it's a multidisciplinary approach, you pass on the message across as well to nurses and doctors that we can all be at par, I know not everyone loves wounds but at least when you're having that basic information on management you can be able to help or maybe prevention of complications on such because you have at least the basic information. Okay speaking of preventing further damage to be done, what would you say is the best course of action to take as fast aid for someone who has fresh wound that you've come across, is it something that you should take care of you know as yourself or you know to help a person before they get to a medic that will prevent further damage? For wounds okay what matters as per say is the degree, there are those wounds which you can be able to manage from home, there are those wounds which definitely needs a medical protection at what end to, for instance those superficial by superficial I mean those that just involve the top layer of the skin, those are things that we just hygiene, cleaning even just basic tap water can be able to resolve and covering them don't leave any wound open, you have to cover regardless of how small it is, so for such this ones can be managed from home but wounds that get now to deeper tissues the skin has got like three layers, the epidermis, the dermis and the subcutaneous layer, anything penetrating past the superficial the top layer then it's of interest to be seen by a practitioner, remember there's an issue of now infection, the skin contains a lot of bacteria which if they find broken skin they get inside can really escalate into something completely different, so remember some wounds involved like if it's deep cuts blood vessels, cutting nerves that's why it's important for them to be seen, it might be even not really of concern but at least being seen comes very important, even injection of this tetanus toxin, those are factors that normally want to have done at least within the first 72 hours after a cut if it's penetrating then go to the facility for that. Speaking of tetanus because I was also coming to that you know we know and we've heard that you when especially if it's a metal metallic object that has cut you then you need to get a tetanus injection is it only limited to a metallic object cutting you or do you just need a tetanus injection if the cut is deep what determines the cost of action? Those cuts that occur injuries which compromises the temperature of the skin that you don't know the origin you've fallen down and you have a bruise, a big bruise, you don't have a look it's important to get the shots. That is whether deep or not? Okay we normally overlook ideally any cut but you see you can't we subject ourselves to cuts almost every day you can't be running for injection every other time so there normally like schedules for getting these shots there's a number of this limit your body now can be able to like fight back remember this anomaly some attenuated viruses so they just weaken so the body can be able to like fight back as well so we advocate for these shots because the complications normally let's say one is subjected to not this tetanus itself it's life limiting a life tetanus because it affects the nerves the nervous system becomes compromised and it can compromise not only the limbs including the respiratory system any system with a muscle can be compromised so you find that it is important to protect yourself get this job you have an injury penetrating or you know the object maybe something rusty or maybe some injury which you don't know how you got it but let's say even after an accident or something you ensure the practitioner gives you the job. Okay all right interesting I think I have missed so much I've received so many cuts I've never gone to a tetanus injection. Some might not be really necessary. All right so now how do you because you've said it for you to handle the situation it determined by the severity of the wound how do you for a normal person ordinary person how do you determine that this needs to get medical proper medical attention it's beyond me because you know as Kenyans we know how to treat ourselves we know so much we have all the knowledge and then we assume we know it all but we might get to us so how do you determine the severity of the situation? For open wounds wounds which don't heal like this what I mentioned about the pattern or the path the course in which wound healing takes so a wound which does not follow the sequence it's not tissues are not regenerating or this continuation or continuity of bleeding or some we find that there is some funny fluid coming from the we call purulent exit the common language is pass coming from it these are clear markers that the wound is out of hand and should have been attended to like earlier on so non healing wounds if you're having any even odour or you're having dead tissues some will manifest even by dead tissues this one's should have been seen in the facility that's why we're saying don't have a look any regardless how simple it looks like don't have a look because there might be some other underlying thing that you're not seeing including even small things like pimples like okay not all are just ordinary pimples some got a history behind so those breeze those deep penetrating cuts anything any discoloration the skin it might be something brewing inside so I just have it seen so you can say that this is too I'll soon I can be able to do at home anything you suspect like I know this is way too much for me as in but don't wait until it gets to that just have it looked at okay and we've talked about what we've talked mostly about is on the trauma type of wound and the open wound before we move on to even the buns what about wounds that I don't know if it's closed wounds and you know where you just have how do we call it you have let's say fallen and then you feel pain from inside and then you have enough for Ram Kono something is that also another type of wound that you would say we normally say if if the integrity of skin is not okay by definition we normally define a wound by it's an injury which compromises the normal integrity of the skin so if the integrity of skin is not compromised it's not a wound but remember there's some physiology switch or some path of physiology switch manifests they begin from inside like something is happening on the inside but eventually it ruptures out causing now a physical wound so you've fallen there is a swelling those ones have to be looked at for instance they might be bleeding underneath the skin or it's an inflammatory injury maybe after attend on tear or rupture or maybe some ligament have been damaged definitely the body responds by an inflammatory weight it will inflame and swell up such kind of injury as well requires to be seen or maybe there is a fracture which is poking tissues on the inside maybe there's an even an internal bleed such kind of things have to be looked at you know seeing grace a physical wound on the outside but inside there might be some damage I'll even talk about maybe things like those pressure ulcers precious ulcers they don't form by just a wound happening on the skin as someone is lying on one position for too long the bony prominence is pressing against the tissue so the injury begins from the inside by the time you're seeing it outside the entire inside is already compromised so even such that's what we normally advocate for even healthcare workers at home like not everyone's in the facility some people being taken care of from home like doing a physical head to toe examination those we normally call pressure areas I just need to assess and monitor you need to know between the good the good tissue looks like so that when you see the bad tissue can easily identify okay all right interesting and now that there's do we have basics or key principles of wound management I know you said a wound is always supposed to be covered you know are there other basic principles of wound management for someone at home who doesn't have a severe wound I will say yes there are principles and guidelines which should be protocols which should be followed okay one is all wounds have to be covered all wounds have to be covered then two if it's at home you should minimize regular dressing changes these days we are having a lot of technology there are dressings materials which are available which minimizes exposure because remember the environment at home might not be completely ideal to expose wounds because possibility of contamination from different surfaces or even from the provider at home so there's no ideal environment for opening a wound at home yes you can be able to create it but it's not that easy so appropriate dressing material most of them can even do five to seven days without change of dressing it enhances quicker healing there is less interference with the the healing process but that one has to be prescribed if not a medical practitioner is coming to do it you should have been given some basic information on how to achieve this serility process how to do the changes because at times maybe you find the hospital is expensive to take the patient but you can be able to learn and do it from home then reporting you need to be reporting to a certain healthcare practitioner that I have exposed this is how it looks this is how it was this is how it looks like now is there anything of concern that you need to adjust or maybe should we bring the patient for a review so even if you're managing the patient at home you need to also I associate with a certain facility but you can be able to be reporting on the progress okay all right let's now talk about the the band for for the band is there what is the best fast aid to do order password before they go to even say the doctor in the event maybe there's a chemical band or from a fire what is the best way to handle someone uh bands is a is a is a very uh interesting kind of a wound it's unlike most other wounds uh you are maybe if I just uh tell you the difference you feel that for other wounds uh these are physical injuries maybe it's a cut yeah or uh cells okay now remember your biology uh cells have been cut so they let me just now read down to that one but now for bands uh they're exposed to heat so we normally say the proteins are becomes uh uh denatured doesn't the the cells don't work normally the cell is there as a whole but it doesn't work normally so healing process is extremely slow or if they they're subjected to uh less or negative thermal effect then the cells becomes deactivated cease to stop stops to work completely so that is why bands are funny and healing becomes a little bit difficult uh so subjected to heat uh the first aid normally say you remove uh the the the the course remove the try to remove the also yourself taking precautions not to be the other the next victim i remove the course if the patient was abated to heat uh with caution uh you cool the wound with caution you cool the wound there's several ways you can be able to do that you apply maybe uh a cloth on top and then something cold on top as in you pour liquid or ice but not directly on the wound uh you put something first like a cloth a clean cloth then uh then and also the issue of uh some couldn't have blisters already do you poke the blisters and such as an entire model as well um the home environment is not a guarantee of sterility that's why normally don't poke blisters uh so those ones need to be seen in a facility um after you've removed the the effect if it's an electrical band uh with caution don't go touching they were trying to pull them off from the cables just switch from the mains switch off from the mains uh ensure this patient is in a clear place also you safe distances from electric electrical cables and such uh then uh for electrical uh injuries those patients have to be seen in a facility because electricity normally impairs uh functions including brain conductivity and heart so those ones need to be seen in a facility as soon as possible try to get options of getting to facility for thermal uh uh events or chemical exposures uh those ones we normally uh need depending on the the severity we normally say anything this how we normally uh calculate percentage of bands uh there are those that will indicate hospital admission those that will just be seen as an outpatient they are released to go home so that those categories that need to be seen uh if you can be able to measure with your palm of your hand this is we normally call it one percent so your body will be covered by a hundred of your palm size uh so one percent anything can be covered by your hand okay have it seen by facility though that's something that can be able to be managed from home but have it seen a facility those like from uh uh above uh these days even if it's five percent okay sometime back you used to admit from ten percent these days even anything more as long as it's deep penetrating into the uh deeper tissues uh regardless of the percentage uh might need to be admitted for what we normally call uh early excision and maybe grafting okay in Alema's language remember you talked about uh the cell being deactivated or damaged you know that it's not responding so if you cut that cell out you convert this wound from a band into a cut into a cut oh yes so it heals quicker faster yes okay so now i'm known cuts heal faster than than bands if the tissues are still there if the tissues are still there okay now what about for um the category of people who have pre-existing conditions like diabetes and those that have HIV uh uh those are some other uh mobiles that has to be managed first uh for instance maybe i can talk more about diabetic uh patients you find that they're having limitations in healing uh because diabetes itself has got complications uh the most noticed complication is normally a reduction of blood supply to areas that's why we find uh patients end up with what we call peripheral arterial disease because the arteries uh collapse there is less of a blood flow to extremities you get these patients are subjected to dead tissues and gangrene uh there are those patients who develop what we call neuropathies they cannot be able to perceive sensation they end up with a lot of source all this contributes to what we call uh diabetic foot ulcers and many other related uh ulcers because of uh diabetes so healing normal or maybe to manage them uh manage the underlying conditions first even for those with the HIV like uh you need to boost on the immunity remember the immunity is compromised uh immunity okay nutrition and so forth it's a lot of things that has to be boosted fast so that eventually even the wound can be able to heal uh for instance there are those basic requirements for a wound to heal uh good protein intake uh that's those are the building blocks for tissue regeneration and repair uh to no infection like uh uh treat uh the the infection or maybe the bacteria that have come in and then uh three we normally talk about moisture balance remember some of the tissues uh there's a lot of or too much moisture in the wound because of either the dressing material put on and such then also the type of tissue that you have are you having dead tissue are you having viable tissue check on them so there's a sequence that they normally follow uh which helps you to identify we we're having like we call it like a time principle that is one of the that help you to assess uh time is an acronym like T stands for tissue inflammation infection moisture balance and the edges so some of the uh acronym that makes it simpler to assess and manage the wound there are several others which are common but that's the key one currently okay all right now back to infections because if you don't manage it well I'm assuming that you'll get infections what are the signs that the wound has been infected and how should one go about it uh infection many manifests itself clearly uh one there is okay there are two types of uh infection there is localized infection whereby it's just the wound that is showing manifestation of infection and then two when this patient is having either spreading or systemic infection so when you want to say a wound is infected there are those local manifest local signs uh localized heat comes a little bit warmer than the surrounding uh change of color it becomes red you call it there's a rhythm uh then the the tissue itself might change color uh to darkening because of the infection infection sets into the wound itself we have change of x-dates color x-dates that fluid coming from the wound can change color becomes purulent or maybe it comes uh pass let me call it pass um non healing is another sign of in fact the wound does not respond well it means there's some deep seated infection uh it's a status normally called biofilm uh so there's some of the common signs that can be put find the patient has got local infection when we talk about spreading infection now the the changes of the surrounding skin call it periwound skin starts to change as well the heat spreads to now the surrounding even change of color now the manifestation of systemic infection for instance nausea and vomiting that general weakness system shutdown loss of appetite i know these are systemic signs of an infection which can be originating from just the wound one okay can you manage an infection at home no uh uh you can that is after uh appropriate uh prescriptions uh because you see at times also maybe the hospital environment might let's say these patients who got immune suppression the longer you keep them in hospital there's this risk of a hospital acquired infection so the safest place to manage them is at home okay uh so these patients are put in prescriptions and they can recover from home but definitely if there's an open wound with regular uh or maybe monitored dressing changes all right so apart from infection what are some of the other factors that delay wound healing um no those ones we call them chronicity what causes chronicities and what delays wound healing apart from infection uh then the lying condition we talked about diabetes uh those vascular issues like this limitation of blood supply that is very naughty uh and the lying conditions are many uh we have irritants or even even the kind of dressing put remember some practitioners maybe they don't have the knowledge of uh this dressing materials you can put something on a wound which will complicate it further instead of improving it it makes it uh become worse um other factors like injury uh you get patients they have a wound then they've injured the same place again so uh also normally it makes it take a little bit longer to heal several factors yeah okay all right interesting now you mentioned that this um there's been a lot of change from how wounds are being treated to how it is now so what is this that has changed over time uh i know what what cuts across like now many Kenyans are from the history you've gone to hospital and guys are using honey and sugar i don't know if you you're too young to remember that you could go to a facility and when it comes to time for dressing you think you're in a supermarket there is this type of a sugar brand honey is from somewhere in uh this some of the old methods uh there's some solutions which are used to clean a wound okay uh not really uh uh demeaning the companies manufacturing them like hydrogen peroxide we have some kind of iodine solution in the market this one should never be put on the wood okay science have proven that they are not right being put on the wound they cause more damage on the cells some some you might not see like immediately but in the long term those are some of the factors that contribute to prolonging the healing time so technology has really come in handy to modify and to have a way of managing infection moisture balance and ensuring the tissues come quicker so there are materials that have been uh engineered scientifically engineered to help with that uh for instance i can just mention a few uh technologies we have uh foam dressing foam just like the mattress foam but now this one is a foam dressing a little bit thinner not like not as thick as the mattress so between uh thinner it absorbs at the same time they are impregnated with antibiotics so you see you put on an infected wood this patient doesn't need to take oral antibiotics so to get shots for antibiotics if it's local and local infection just put a local antibiotic to it so it's a dressing it takes up the moisture and releases antibiotics it helps the wound to dry up quicker so it it it removes those older ways whereby you found patients just these are patients directly with gauze you've seen uh just a normal gauze put directly on a wound these are some more things gauze it doesn't it doesn't have any medical benefit on the wound actually it's like a foreign body but these ones have been engineered to absorb so we have others like we call hydrophibers or alginates these ones are put in those deep wounds they stimulate granulation and tissues to come up quick we have any technologies like negative pressure wound therapy it's a device connected on a patient it's portable uh it takes out the x-dates minimizes contamination even post surgery we use them a lot when we're doing post surgical uh management or prevention of what we call surgical site infections uh then interventions like uh uh growth factor concentrate those there's some injection just get blood from just get some blood from you we separate growth factors and everything so growth factors are injected back they stimulate quicker the the same growth factors we use when when uh even regenerating uh hair those with hair thinning and uh partial hair loss which is not really genetic uh so by that it stimulates even hair regeneration so when you even give it to a wound it regenerates a new tissues growth we're having the same of uh the protein rich plasma with the prp injections just from the blood you you know the body is compact it has everything it needs okay so we just get those ones concentrate them and put them back they help these are uh ways of making things up and quicker okay so technology has come to change things up and make things better thank you very much for this amazing insightful conversation Dr. Kennedy is there one thing that you want to advise the youth regarding uh from everything that you've said regarding wound treatment healing and care if you have that that's the camera also you can share your handle where people can get you yeah um for the youths okay this is a it's a it's an interesting uh group uh i know they are the ones who are at risk actually uh most uh trauma related wounds we get them uh affecting this particular age group uh from uh accident fights uh because of exposure they're really trying to explore to explore more so you find that they they end up with a lot of injuries so go slow be careful on uh whatever you're doing whichever activities don't engage in activities that will uh put you at risk of injuries and uh subject you to wounds and uh uh yeah i think that's what i can go tell the youths just to be careful careful with themself right they are at risk of a lot of injuries i know that those that come because of age that this will come because of lifestyle but the majority is those that are caused by trauma trauma wounds uh as in composite of the majority percentage yes so the common type yes yes so and the youths are the ones who are at at risk very active yeah uh to get me uh on my social handles uh k medicine consult that cuts across all the social platforms k medicine consult uh i'm available at uh 40 suits upper hill uh those for those who wants to physically come to to see me at a clinic okay thank you very much dr kennedy we appreciate you sharing uh the insightful uh comments on this particular topic that has been us discussing on uh you know wound healing treatment and uh care with dr kennedy i hope you've taken something from it you bring a youth make sure you tread carefully when you're having fun out there whatever you do make sure you take care of yourself there has been a health conversation we're going to take a short break then we'll be coming back to sample some of your comments on social media on the question that we asked you how do you create a balance between work life and your family talk to us the hashtag is one in the morning then after that we're going to have entrepreneurship uh we take a short break we'll be right back


Good afternoon. Seeing it's 1 o'clock, we'll call to order the green man care boards meeting of February 1st 2023. Today, we'll be hearing from Dana, who land from the agency of human services. Dana is the exchange project director, and we'll be discussing the 2024 standard qualified qualified health plan designs. And 1st, we'll take up the minutes from January 18th 2023. Is there any board discussion relating to the January 18th meeting minutes? Is there a motion to approve? Yeah, so moved. Second. All those in favor, please say aye. Aye. Aye. And the motion carries and the minutes are unanimously approved. And with that, I'll turn it over to Ms. Susan Barrett for the executive director's report. Thank you, Mr. Chair. Some scheduling announcements are scheduled for February for our regular board meetings at 1 p.m. on Wednesdays is posted on our website under board meetings. I also want to announce that on Monday, this coming Monday, February 6th. The board will be having a general advisory committee meeting with our general advisory committee and that starts at 2 p.m. and that's held virtually through teams on Monday. In addition, on February 15th, we'll be meeting with our primary care advisory group and that meeting starts at 5 p.m. Again, February 15th. It's a Wednesday. That also is virtual and for all of those meetings, there is a physical location if folks cannot access the meeting through teams. In addition, I know as a chair foster, we'll be hearing from Dana Houlihan today and his team on the 2020 for qualified health plan designs and we opened a public comment period on January 31st. That public comment period will run through February 7th and the board has a potential vote on these plans for February 8th. So, if you could get your comments in to us, so they could be considered ahead of the vote, that would be helpful. And last, but certainly not least, we have an ongoing public comment period regarding a potential next model with the centers for Medicare and Medicaid innovations and CMS. We are accepting any comments on that next model and we will share those with the administration and our AHS as they are leading the negotiations and the all pair model. And with that, I'll turn it back to you, Mr. Chair. Thank you very much. I'll just turn it over directly to Mr. Houlihan and Dana, if you could please introduce your team and take it away. Thank you. Yes, thank you. Let me just, okay, we're sorted out now. Good afternoon, everyone. Dana Houlihan from the Department of Homeland Health Access. I'm the plan management director. And I'm joined by Addie Stermelo, who is our deputy commissioner at Diva, and by Darren Johnson, Julie Pepper, and Alex Taraki from Wakeley Consulting, our editorial partners for this process. So we'll start with comments from Addie. Take it away. Thank you, Dana. Hi, everyone. As Dana said, my name is Addie Stermelo. I am a deputy commissioner at the Department of Vermont Health Access. I traditionally come with Dana to provide some kind of opening remarks in some context ahead of the plan design presentation. In my capacity at Diva, I oversee eligibility and enrollment. And as you may know, at Diva, we have an integrated marketplace that performs eligibility and enrollment for Medicaid, in addition to qualified health plans. So I wanted to offer a few comments about other things that are kind of going on in the marketplace right now that you may have read about or otherwise heard about, just to provide some context, even though they are not directly related to the plan design presentation. The first relates to Medicaid renewals. So since 2020, Diva and all Medicaid agencies across the country have been keeping people on Medicaid pursuant to a federal policy during the pandemic. So Vermonters have remained on Medicaid, even if they no longer qualify. This protection called continuous coverage was established by Congress in conjunction with increased Medicaid funding during the public health emergency. And this measure has been in place to help ensure as many people as possible keep their health insurance and access to health care during the pandemic. So during the last three years, our enrollment has grown because of this. It's grown by over 20 percent. And our marketplace enrollment, which you will see when we provide that data, I think in our next presentation, has actually been down because of that, because we haven't seen that usual churn between the programs. About a month ago, Congress passed a bill that ends that continuous coverage requirement for Medicaid. So starting this April, Medicaid renewals will begin again. Renewals are the term that we use for the federally required process to recheck eligibility for Medicaid every year. This is what was suspended during the continuous coverage period. And it will be starting up again this spring. I think one thing we want to make clear to everyone is that it's not a change with respect to who can be on Medicaid. It's just returning to normal processes. But it is going to be a change generally because there are people who have been on Medicaid for three years without having to engage in this process. So we've been we've been planning on it for quite a period of time now. And I think a few key points that we wanted to share with you all is that this will happen gradually over a period of a year or more. Members will get special communications when their renewal month is coming up. And so we're taking some special steps around communications, making sure we have updated contact information, special messaging, streamlining the renewal process itself, maximizing use of data sources and trying to minimize needed outreach to Vermonters on Medicaid. And then also just really trying to facilitate transition to other coverage to the extent that people find out that they're no longer Medicaid eligible through this process. So that brings me to my second topic, which is the marketplace subsidies. Since we were last before you there have been some major improvements related to the subsidy availability in the marketplace. First, the federal government fixed what is known as the family glitch, so improving access to subsidies for families who have an offer of employer-sponsored coverage. Second, Congress passed the Inflation Reduction Act, extending the expanded premium subsidies that were created by the American Rescue Plan Act in 2021 all the way through 2025. So that was a big relief last summer, not only for purposes of open enrollment, but also in terms of this prospect of returning to Medicaid renewals and the prospect of having some people coming off of Medicaid and into the marketplace want to make very clear that if someone is no longer eligible they will have for Medicaid, they will have that opportunity to enroll in the marketplace and get help paying for it thanks to these federal subsidies. We will, I think there was a question about this, we will have a special enrollment period for anyone coming off of Medicaid so there's not going to be any kind of policy barrier to marketplace enrollments during this restart process. The last topic I wanted to bring up again not directly related to the plan design but just for context is that there is a proposal in the governor's budget this year to eliminate the Vermont Cost Sharing Reduction Program in 2024. So this is what we call VCSR. It's a state funded program designed to reduce out-of-pocket costs for eligible qualified health plan enrollees. It was designed as a wrap for the federal cost sharing subsidies for those with household incomes 200 to 300 percent of the federal poverty level. I'll just briefly say I think the thought behind this proposal is that given the way Vermont's kind of consumption of the federal subsidies has evolved since its inception the program isn't filling kind of as critical a role with respect to affordability that it was intended to and may not be the best use of state dollars. But this is just a proposal and it, you know, I think there's a long way to go before we know if that's actually going to kind of come to be for 2024. It wouldn't impact plan design but it would impact kind of the rest of the QHP certification process. So the QHP stakeholder group, you know, discussed this and decided to kind of proceed with filing the forms as if VCSR will remain in place. And then if the proposal does pass the idea would be to pull back the forms that are specific to those the VCSR tier 77 silver 77 tier. But that gets a little bit technical. You'll see in some of the slides that that tier is reflected. But again, the thought is to kind of do the form filing based on current law and kind of and go from there depending on how the session goes. So I think that covers my overview. It's going to be a busy season, busy year in the marketplace, and we appreciate your partnership. I'm happy to take any general questions, but I know we also have a lot to present that is specific to plan design. So thank you for your time. Thank you, Adi. I have one quick question that the number of people who've been enrolled in the expanded access that are that will be unenrolled, did you have a number for that? I missed it. No, we're not going to give a projection around the number of people who might lose Medicaid. I mean, what I can say is that our current enrollment is around 200,000. We have to renew all 200,000. And whether someone remains eligible will depend on what's going on with them, their personal circumstances and their participation in the renewal process. I can say that we're going to in the renewal process prioritize the subset of the Medicaid population that's already told us they're no longer eligible. So they've reported additional income or change in job so that we can facilitate that transition to the marketplace as early in the process as possible. So just we do have those kind of subpopulations that we can talk through, but there's no actual projection for the number of closures. Okay. Okay. Thanks. I have one quick question. Adi, when you come in with the number, the enrollment figures next week, will it be clear how many folks are in the Silver 77 or from the current enrollment? Dana, do we get that granular in the enrollment tables? No, generally it's aggregated, but there's no reason we couldn't pull out that number. Sure. That would be helpful. Thank you. Just to understand the impact, potential impact, I should say. I'm making a note. Thanks, Dana. Okay. Shall we begin? Can everyone see the screen? The presentation all set? Looks good, Dana. Okay. Thanks. So I'll just begin with a few slides to kind of frame up our discussion and provide some context about our process to build this presentation. Then I will turn it over to Wigley Consulting to make art to present our proposals and first to describe the federal guidance changes within the 2024 payment notice. These change every year in addition to a something called the actuarial value calculator used to guide this process as well. So those are the important objectives for today and then between this meeting and next week, we will gather comments, questions, and further discussion in preparation hopefully for the vote next week. Thank you. As a reminder, just for context, there are 14 standard and 14 non-standard. That's seven each category from both issuers. We are focusing on this section right here, not the non-standard plans, which are just not part of this process. So we're focusing on it's one platinum, one gold, two silver, and three bronze for each medical issuer. We're worried about our stakeholder process and composition. Was there a question? Let me speak over anyone. We have a stakeholder group that begins meeting in mid to late November and we meet weekly, finished our discussions and decisions last week. In fact, in preparation for today, we have representatives from all of the issuers. We have two representatives from the healthcare advocate's office, important for the consumer perspective in particular. And then of course we have representatives from DFR and the Green Mountain Care Board as our other regulators in Vermont for the exchange. So if we have active discussion at each meeting, weekly consulting provides us with planned modeling. We look back at the changes that have been done in previous years, factor in the changes for the upcoming year and what would need to change in terms of the benefits to remain compliant or to make our best proposal for the following year. We come to consensus when we can, not always possible, but this year I believe for every one of our decisions after a robust discussion we did have consensus, which is good. I won't read these, but these are principles that are in our minds as we go through our process to make the best decisions that we can within the options that we have for changes and to make, as I said, the best possible set of decisions for standard plans for Vermonters. Another word on affordability here, we thought it was important to add specific to the plans at the silver level. The silver plan, both issuers have four silver plans, so that's eight total. The silver plan, the second lowest cost silver plan is used to calculate APTC, so it's a significant factor for affordability, of course. Generally speaking, the higher the AV, the higher the premium it will be. So we just wanted to add a statement that the DEVA, the state, favors and supports the concept of trying to maximize the AV at the silver level in an effort to maximize subsidy for Vermonters who are eligible. And there'll be more, this last point here about the AV ranges. There'll be more detail on this later in the presentation, but in the last couple of years, the federal guidelines have impressed the range for acceptable silver plan AVs. So it's narrowed on the upper side. There's typically B, for example, 70% plus or minus 2%. For silver plans, there's no longer an ability to go below 70%. It's 70 plus two. There'll be more detail to follow in that. More about our process. As you'll see with each one of the plans, we are required to make changes to bring a plan into compliance if the AV using the new calculator would be out of range. In some instances, even if we are within range, our approach is to do smaller incremental increases year over year rather than holding back and then being required to make a more drastic change in future years, which could be difficult for consumers. So we're trying to be mindful of overall cost for a plan and affordability in terms of the out-of-pocket components. And then, of course, we always try to avoid any kind of a benefit design that would be difficult for consumers to understand and use. I wanted to make the note too that silver loading continues in 2024. This is the mechanism to fund the CSR program. And this is done by most exchanges in the country. So that will be continuing as usual for 2024. And then lastly, I wanted to just pull out a few things important in the timeline. I did provide a comprehensive 2024 timeline document for the board. But just some of the highlights are that we are in the first step mentioned here before the board for presentation of the design adjustments for 2024. In March, the issuers will submit their form documents, the summaries of benefits and coverage and contracts to DFR for review, which will conclude in June. We expect to have the final parameters from CMS and IRS limits in the spring of 2023. That's typically when it's been received before. In May of 2023, the issuers will make their rate proposals. That begins a process, as you're well aware, with the board through rate review and hearings and decisions in August. Also, in August, following final rates or receipts is the Diva commissioner formally completes certification of the plans to be offered on the exchange. And then from there, it's all many, many steps to prepare for open enrollment, which will be November 1st of 2023 to January 15th. So from here, I will turn it over to Darren. Can you see my screen? Seeing some, that's not perfect. Yeah, so my name is Darren Johnson. I'm a consulting actuary with Wickley Consulting Group. We help with the actuarial portion of the standard plan analysis. And I'll just kind of take you through the work the stakeholder group has been doing this winter. So quick outline of what we'll be covering. We'll spend some time going over kind of the proposed regulation changes for 2024, coming from the federal level, what changes we've seen in the federal AB calculator that will impact the ranges we can have for the standard plan designs, and then the stakeholder group recommendations for each plan design changed by metal level. So we have the 2024 draft notice of benefit and payment parameters. As Dana noted, we'll have a final one coming out in the next couple of months. We use the draft one for this portion. We also have the annual limitation on cash sharing that was released in a separate guidance letter that is finalized, setting the limit for individual maximum amount of pockets at $9,450 for 2024, an increase of $250 from 2023. Separately, we do not yet have the federal HDHP minimum deductible and moop limits. We have the ones from 2023 because of kind of past experience. We don't really anticipate a 2024 deductible increase. In addition, because the the moop for HDHPs was increased by so much last year, we don't necessarily anticipate a 2024 moop increase either. We'll see what happens when that is released. For the proposed plan designs, we assumed that the deductible would remain at the same level. If that limit is adjusted, we might need to tweak the pharmacy deductible for some of the HDHPs. There are other changes not listed here. We thought these were the most material ones to the plan designs. So we also have the 2024 draft actuarial value calculator. Again, this one is still in draft status as well. The final one should be released at some point in the next couple months. Typically, we do not see changes between draft and final, but you never know when you might get a curveball. This model is used to determine the actuarial value of the plan for the purpose of bucketing a plan into those different metal levels. I hope it includes inputs for a lot of different plan design features, your high-level deductibles out of pocket maxims, as well as copays and coinsurance for a number of different service categories. There are plan design features that are not supported by the AV calculator. If these features are substantial, we can either try to modify the inputs to account for that or separately adjust for those plan design features. We'll talk about this more in a little bit. Note that again, the AV that comes from this calculator is not the same as the pricing AV that carriers will calculate as an input into the premium determination process. This calculator is based on summarized national data. It's not Vermont-specific. You have limits to how much you can calibrate the data, and then there's those plan design features that are not necessarily supported that could differ, as well as potentially mythological differences between the federal AV calculator and issuers individual AV calculators. So again, just draft format. There could still be changes, but what were the changes from the 2023 final to the 2024 draft? They stuck with the same data. It's 2018 individual and small group data, again, national data. They're trending it from 2018 to 2024. To trend from 23 to 24, they used a 5.4% medical and 8.2% pharmacy. You can kind of see in the table down below what that means for the allowed PMPMs at the different metal levels. There were some changes to the AV calculator logic this year. That doesn't always happen, but these ones are actually somewhat noticeable. So that first one, especially the copays, no longer accrue towards the deductible. The AV calculator in the past, it had a bit of a deficiency where it would accrue copays on primary care or generic drugs or whatever towards the deductible, which from our experience is not how issuers actually adjudicate those benefits. So by removing that change, that drove actuarial values down a plan that doesn't accrue copays towards the deductible is less rich than a plan that does, which helped this year by reducing the magnitude of changes needed. The increases in cost sharing needed to ensure that planes were still in compliance with those AV ranges. So this is a one-time thing. It's probably not going to change in future years, but definitely helped this year with reducing the magnitude of cost sharing increases needed to stay within those ranges. There was another adjustment for the calculation for planes likely to meet their maximum out-of-pocket for the deductible. That's pretty rare. It's a much more minor adjustment, but just wanted to note it. So this slide has a lot of words on it, but is definitely an important slide. So as we go into the plan designs, we're going to show an estimated premium impact in addition to the change in the draft and the actuarial value, federal actuarial values from last year to this year. We're going to show this estimated premium impact as well. That's meant to show that there is a bit of a trade-off between premium increases and cost sharing increases. If you make a plan richer, the premium gets higher. If you make a plan less rich, the premium gets lower. This is based on a Wakeley model that is based on national data. We calibrate it some to Vermont specific experience, but obviously there's a limit to how much we can do there. There's things we don't adjust for that the issuers certainly will. This premium change does not take into account a number of different variables that again the issuers will when they're putting together their actual pricing for this coming year. It's really just meant to kind of illustrate the impact to the actuarial value from plan design changes and from sort of trend year over year. Yes, so given this new actuarial value calculator, what's kind of the landscape of changes that we're looking at? Changes are required for the bronze deductible without drug limit plan and the silver HDHP plan. The plan designs from the previous year are no longer compliant. They're not falling into the required ranges by maybe calculator. For all the other plans, even if changes are not required, we generally still kind of lean toward changes to avoid the AB increase either being passed on as premium increases or requiring larger changes in future years. There were also some changes required on the silver CSR plan designs that we don't cover as much in this presentation. That information is available in the appendix if you want to look at it. The acceptable AV ranges below, we'll go into that on the next slide, reflect both the changes in the draft MPPP and then there's a number of kind of the side adjustments we have to make to the calculator because it does not include the full range of possible plan design features. So HDHPs in Vermont waived the deductible on preventive prescription drugs. The issuers kind of looked into that assumption again this year and confirmed that adding about a 0.5% cushion was kind of a way to model that. In addition, out-of-pocket expenses are limited for insulin. We did some modeling on that last year. It seemed like it only really had an impact on bronze plans. We're kind of added a little extra cushion on the high range of the plans. And then lastly, last year, all non-HDHP plans except bronze without drug limit had three free mental health and substance abuse visits as well as three PCP visits. The AB calculator does not support free mental health and substance abuse visits in its modeling. So we added this small multiplicative factor where we get a final AV and multiply it by 1.001 and then that's our final final AV and that's what we use to check compliance. So what does this all look like? Just to take an example, a silver plan last year or 71.7 this year is 70.9. So it actually decreased substantially. That is not normal. That is due to the change in methodology with how they're handling co-pays. The acceptable range is 70 to 72. That kind of goes back to Dana. It used to be 68 to 72. As he said, they kind of lopped off the bottom. So now it's 70 to 72. The bronze HDHP plan last year was a 62.9. This year it increased slightly to 63.1. The acceptable range to that is 58 to 64.4. The federal requirement would be up to 65, but we add that cushion the 0.5 percent for the preventive drugs and then the 0.1 percent for the insulin limitation. So you can kind of see how all those ranges get adjusted based on those requirements. And then as noted, the bronze without drug limit and the silver HDHP were ones that are now outside of the top end of the range using the plan design from last year. There are, after we make changes to these plan designs to kind of get within those ranges or balance premium impacts, there are some changes that require formal approval from the Green Mountain Care Board. This year there was only one kind of primary plan design that we chose that required that it gets outside of these ranges. We'll get to that in a moment. One other change that came this year was updating Vermont's EHB benchmark plan to include hearing aid coverage, both an annual exam and then one hearing aid per year every three years. The stakeholder group decided that the annual exam will be covered the same as specialist office visits, and then hearing aids will be covered the same as durable medical equipment, which is typically deductible in coinsurance. This has a minimal impact on plan design, actual value. We don't think any additional calculations are required. So before I hop into kind of the meat of the presentation, were there any questions from that long intro? Perfect. So this is just kind of a summary slide of all the changes we've made, just kind of to refer back to. As noted, highlighted in green is the one plan where we have a kind of a primary recommendation that is exceeds the limits for Green Mountain Care Board approval, requiring Green Mountain Care Board approval, and we'll touch on that more when we get to that plan. So starting off with platinum deductible. So on this slide, we're kind of showing the history over time of how this plan's cost sharing has changed. As you can see, generally, we're kind of trading off between loop changes, deductible changes, some years have both. Last year, we brought in the three free PCP visits and mental health and substance abuse visits. So this slide, we're showing the 2023 plan design, the kind of preferred option the stakeholder group decided on in our meetings, and then kind of a backup option that we wanted to also present. So here, we recommend it minor changes to the medical deductible, a $25 increase. We recommend it keeping the medical out-of-pocket max the same and a minor increase to the pharmacy out-of-pocket max to kind of bring it up to that HGHP limit, just kind of as a general place that we're taking things. This should have a pretty small impact. On ABC, it just decreases slightly from 90.2% to 90.1% compliance with the AB calculator is not really an issue here. We're pretty far from that 92% target. And the premium impact is pretty minor. We see a slight premium impact increase. If that seems confusing that we're reduced, there are reducing benefits and seeing an increase. What we're also modeling here is the impact of kind of leveraging. So we're modeling claim costs increase 23 to 24, which makes a given deductible level a little richer. So even if we kept the plan design the same, there would be a 0.4% increase in premium. So we're just cutting that back just a little bit. And that's kind of the recommended option there. So as mentioned, increasing the cost sharing, even though the plan design is within the AB ranges, we're recommending minor changes just to limit the impact on premium a little bit, you know, help avoid larger changes down the line and increase the pharmacy loop just to be consistent with the HGHP pharmacy loops onto the gold deductible plan. Again, just kind of showing the changes in cost sharing over time. I do want to note this plan has had deductible increases for the last four years, including a couple of years where there have been $200 deductible increases that definitely played into our decisions with this plan. So with this one, our preferred option was leaving the deductible alone, kind of giving consumers a break on the deductible and the medical out-of-pocket tax this year, increasing that pharmacy loop again to that 1,500 level. You'll be seeing that a lot. And then kind of achieving the reduction goals by focusing on co-pay increases instead. So you can see we kind of added $5 to a suite of co-pays, $3 to a pharmacy generic co-pay, allowing us to bring the 2024 ABC down a decent amount and limit the premium impact as well. You know, again, this plan is also under the target, even with the 2023 plan design, but if it's an 81.9% this year, next year, you're probably going to see, you know, a 1% increase or more in ABC. We just kind of avoided that this year because of that methodological change. So we think, you know, change of this magnitude is going to do a lot to prevent needing, you know, kind of the dramatic changes we've had in the past by spreading things out a little more this year. And then the backup option was just if we wanted to kind of get even more breathing room or cut premium impact even more, adding in a change to the medical out-of-pocket max and then adding in an ER co-pay increase as well. So as mentioned, we're trying to kind of cut those deductible increases after multiple years of increasing those limit premium impact. We're keeping the three free visits on PCP and mental health and substance abuse and then increasing that pharmacy moop. On to the silver deductible plan. Again, we're showing the year-over-year changes. This plan has deductible increases pretty much every year, aside from 2021. And again, brought in those three free visits last year. With this one, the 2023 plan design again is actually compliant with the 2024 calculator. This one again benefited a lot from that co-pay methodological change because a lot of services were covered with co-pays on this plan design. So the preferred option that the stakeholder group came up with was just kind of minor out-of-pocket max increases. Again, leave the deductible alone for a year. Just gain a little extra space next year against the AB calculator limit premium impact a little bit. And then we had a backup option where we just kind of really give consumers a break for a year, only increase the pharmacy boop, and then next year it might get a little tighter depending on the changes to the AB calculator. Next up, we've got the silver HDHP plan. So apologies for the giant slide here. It gets a little bit of a mouthful to describe the aggregate deductible structure. But this plan, again, has seen kind of deductible increases year over year, including a pretty substantial one last year. And then most years, moop increases as well. So on this one kind of similar to the gold plan, the stakeholder group recommendation was to again give consumers a break on those deductible and moop increases and instead focus on the co-insurance. So increasing co-insurance kind of across the board by 5%, as a way to get under the target without really hitting the deductible and boop hard. This plan is one that the target is that 71.5% because of the preventive pharmacy cushion we have to add to make sure we're in compliance since it is an HDHP. So the 2023 plan was at 72.3, so a pretty decent amount over that target. So increasing the co-insurance brought it down to a 71.3. So we're even then just not under the target by a whole lot. We did have a backup option if the co-insurance increases were not the direction we wanted to go where we use deductible and moop increases instead to get just under that target. But that requires a $200 deductible increase and a $450 increase to be out of pocket max. And then we'd want to know if something does happen to that HDHP minimal deductible when we get that released, we would have to adjust the pharmacy deductible and out of pocket max. I would not expect that to have a huge change on the final values. So again, yeah, similarly to the gold plan, we're just trying to kind of cut the trend of those large deductible and moop increases and switch things up a little bit while still limiting premium impact and getting into compliance. On to the bronze deductible plan. So not an HDHP, just the bronze deductible plan that has the pharmacy limit. So again, we're kind of showing the changes year over year. This one of note that drug deductible began being waived for generic scripts as well as preventive in 2021. And then last year, we just had a change to the out of pocket max and avoided deductible increases. So this year again, with these bronze plans, the target is so wide with that expanded bronze range from 58 to 65% that compliance with the AB calculator is not really an issue with these plans. It's more a question of trying to limit the premium impact because we generally expect that the consumers purchasing these bronze plans are going to be a little more cost sensitive. So again, with these, it's more about the premium impact than the AB calculator. As we can see our target is 64.9%. We have that 0.1% for that insulin cost sharing limitation and our last year's plan is at a 63.3%. So we're obviously way under the target. It's just more a question of the premium impact. So in this case, the stakeholders were kind of thinking, leave the deductibles where they are. This plan has generally, the MOOP has generally followed the maximum MOOP as it has changed year over year. Sometimes it's been a little lower, but a lot of the times it's been at the level of the maximum MOOP. So the primary recommendation was to continue with that, bring the MOOP up to that 94.50. Again, bring that pharmacy MOOP up to the 1500. That brings the premium impact just from plan design changes at right about a 1.1%. We did model just to see if we increased the pharmacy copay to $20, which it was in the past before 2021, brought it back up to that $20 amount, what impact that would have. And we didn't see a huge impact to premiums from that, just a little more than 0.1%, but wanted to include that as another option if we felt that premium impact was on the high end. Then on to the bronze deductible plan without the pharmacy limit. So this plan is just a pretty straightforward deductible equals out-of-pocket max plan with some free PCP and mental health visits starting last year and a selection of copays. So this is the one where we do kind of hit that green mountain care board required limits. Again, this is a plan that has typically had deductible and MOOPs pretty much at the maximum for the given year, just $100 less last year. And this was the other one where the target is 64.9%. Last year's plan design was at a 65.5%. So again, we're pretty far over the compliance threshold. So the preferred recommendation here was bring it up to the 9,400. That gets us kind of under the limit and gets a premium impact of less than 1%. And then we had a backup option of just going all the way up to the federal limit, the 9,450, which gets a little more breathing room for next year and lowers the premium impact just a bit. Because yeah, I think the 64.8 is like a 64.89. It's kind of right at the limit. So next year, this plan will probably be kind of right at the limit of compliance again. And then lastly, sorry, else is freezing. There we go. Lastly, there are Brown's HDHP. So again, just kind of showing the changes over time. It's just been at the 50% co-insurance is the maximum co-insurance you can charge. So we've stayed pretty much everything stayed kind of constant on that end, just deductible and loop increases year over year. And then the direct deductible is only waived for wellness scripts. So the recommendation this year, I apologize. It looks like I did not include the target on this slide for Brown's HDHP. It would be 64.4%, I believe. Again, we're at a 63.1. We're way below the target. It's just a question of premium impact. In this plan, we were showing a pretty substantial premium impact. Again, that's based on a wakely model. It's not calibrated fully to Vermont expectations. So that caveat applied. But we still, the stakeholder group still kind of felt that this plan has had pretty substantial deductible changes over time, kind of every year consumers have been getting hit with those increases. So the primary recommendation was to limit the deductible increase, just increase the pharmacy out-of-pocket max a little bit and have that premium impact maybe a little bit on the higher end, but reduce the cost sharing. A backup option was to increase the deductible as well. With this plan, it seems like the out-of-pocket max is more what changes the premium impact as opposed to the deductible. When you have 50% co-insurance, once you hit your deductible, you're still paying a pretty decent amount of cost sharing. It's really once you hit your out-of-pocket max that you're realizing higher savings. So there wasn't a huge change on premium impact from also increasing the deductible, but wanted to include the modeling for that option as well. And then again, since this is an HCHP, if that minimum deductible changes, we will have to adjust the modeling slightly for that. So again, just back to the total summary of recommended changes across the plan designs with the Browns Without Pharmacy Limit Plan being the one that kind of exceeded those green mountain care board thresholds. Any questions from that? I know that was a lot of dense x-rayal terminology and modeling, so thank you for sticking along. And then yeah, I know we include a number of appendices with some more detailed modeling, including the CSR plan designs and the silver-on-and-off exchange differences as well as the proposed federal standard plan designs. If you wanted to look through those. Awesome, thank you for your time. Thank you. Owen, are you on? I just want to make sure there wasn't an internet failure there. Okay, good, great. Come on, yeah. Dana, do you guys have more or are you guys complete on your end? That was our intended presentation for today. I expect that we would return next week with other information on enrollment and responses. Any other questions that may be raised between now and then? Okay, great. So I'll turn it, I'll open it up for any board questions or comments now and we're not going to have a vote this week, but I'll open up for board questions or comments. I do not have any questions or comments. Dana already anticipated my annual question about getting enrollment information. I don't have any either. Thank you, Owen. Thank you, Dana, and team for the presentation. Okay, I'll open it up. One question. I'm sorry. Go ahead, Dave. The one question I have is, and sorry to both of you, because I'm very new to this topic in this level of detail, but do we evaluate whether or not these, I mean, I know these plans are defined by federal guidelines, but do we evaluate whether or not we would consider these under insurance, in particular the bronze plans? Well, I guess I would just respond that in the framework of the Affordable Care Act and the bronze level that these do meet all of the you know, required coverages and so forth and the actuarial value, meaning the portion that the insurance companies pay versus the enrollee, but the out-of-pocket costs are substantial, especially in the lower, less rich metal levels. There's no question. A little bit of history might be helpful, which is originally when the Vermont, when Vermont was designing the exchange, the state actually tried to get out of offering bronze plans because there is such a high cost-sharing burden, but that was not allowable under the federal provisions. I just look at those cost-sharing percentages and think about, you know, I'm sorry to like burden everybody with like another thought from the emergency department, but like a patient who comes to the ED who's, you know, fairly healthy person says, okay, I'll get the bronze plan and then ends up with, you know, right lower quadrant abdominal pain, gets labs, a CT and they've got appendicitis and, you know, whether or not they go to surgery or not, like that adds up a lot and at 50% co-pay, you know, you're going to run right up to those out-of-pocket maxims, which is a lot of money and an unexpected cost. So, you know, I understand why we have it and it's just daunting to think about that impact on someone's financial well-being. David is. And one thing, you know, it might be obvious to everybody, but one thing that I remind myself of with each of these presentations, it's easy to get confused. Like max out-of-pocket doesn't include what you pay towards your premium, which comes out of your pocket, right? But it's premium and then the additional things. And your co-pay may not work towards your deductible. So, there are different streams that can continue to add up in very daunting ways. And I think it's important to just keep, be mindful that we be mindful of that. That's a good point. I just want to remind folks that the design of our plan comparison tool is to take those factors into account. It's the combination of premium and out-of-pocket costs and the higher the premium, the lower the out-of-pocket costs. But I think it really depends on a person's situation and expected utilization and all of these factors that are hard to have a perfect crystal ball. But there's definitely trade-offs there. No question. I appreciate the tool a lot. It's nice to be able to create different scenarios and try to think through them. I guess the other thing that, and I don't know if this is an appropriate question for this forum, but as we go through this Medicaid redetermination, people may be leaving Medicaid as an insurance and moving to something like a subsidized silver plan or maybe a bronze plan and the out-of-pocket costs could be substantially higher for individuals the way I see this. I don't think we have any modeling on that, but it sounds like this could be pretty impactful for a good number of homeowners. It would be nice to know more about what that number is about how many we expect to be coming off. I think it's also telling that with them coming off and coming off and having gone on, according to some theories about hospital finance, the amount and number of the amount of enrollees and the amount reimbursed for enrollees should affect commercial prices in predictable ways. We have not seen that in the state, according to the data, an outdated theory that's continued to be prevalent in our state. Thanks for the presentation. Okay. Unless there's any other board questions or comment at this time, I'll turn it over to the healthcare advocate. Sorry. Oh, sorry. Sorry. Just one more thing. I was holding till the end, but go now. There's a statement often in this presentation and others that we have about insurance that gradual increases are needed to avoid larger increases later. And that has such a commonsensical ring to it. It makes you almost don't want to question it. But I question it. It seems like every year we can say, well, we need to do this increase because it will prevent bigger increases later. But I don't know if it's ever prevented a big increase later because we've had big, big increases later, even after the little ones. So I question that statement. That's it. Thanks, Owen. Of course. Eric, I think I believe I heard your voice. If you're ready, please go ahead. So we appreciate the collaborative process and support the board approving these. I will note, this is a decision space that's substantially constrained by federal AV requirements. Dr. Merman, I think you raised an interesting point about bronze. I will note that it exists at many metal levels.  I think my deductible, which we came within maybe $200 of hitting last year, is close to a grand. And I mean, I would consider myself a professional who is well above the median income. And that's like two months salary. I mean, it was substantial decisions had to be made for our budget. And it's very troubling to imagine what a household who does not have the means, which is a vast majority of Vermonters faces. And that was a difficulty that we had on a gold plan. So I can't even imagine. I honestly cannot even imagine what it's like to be on a bronze plan and to be making the median income. Thank you. Thank you for that comment very much, Eric. And it's true. When you do the math and then compare it even on anyone, any of our family incomes, you can see the challenges that it presents. And it is difficult to conceive of how those numbers work at various income levels for families. But thank you for sharing that comment. And I'll open it up to the public for public comment at this time. If you can use your raise your hand function, I'll call on folks. Okay, it looks like no public comment today. And with that, I'll thank you, Dana, very much for your presentation today. And we'll see you again soon. Thank you. Thank you all for your time. Appreciate it very much. Thank you. And with that, is there any new business to come before the board? Any old business? And is there a motion to adjourn? So moved. Second. All those in favor, please say aye. Aye. Aye. Aye. The motion carries and we are adjourned. Thank you. Have a good afternoon.


First off, an apology because this tutorial is mostly going to be me talking because this series needs an introduction and explanation. But we will do a little bit of command line work here to video editing today. And basically, the reason I want to talk a little bit is because a lot of people will be like, why would you want to edit video from the command line? Well, I've got two good reasons. Now, if you plan on making a movie, no, you probably don't want to be doing too much editing from the command line. You're going to want to use a program similar to like Caidon Live. That's what I've been using for the last year and a half, two years for pretty much all my video editing, besides a little bit of blender here and there. And it's great. If you've used Caidon Live in the past and you didn't like it because it crashed or something like that and ran like crap, yeah, a year and a half, two years ago, it wasn't that great. And in the last year and a half, two years, it has come a long way. And it does everything I need pretty much, and what it does in blender does. So I'd recommend checking that out. And if you're going to be doing video editing as far as a movie, that's a great. And if you're not command line person or shell person, this is a great program. But two reasons that you may want to edit or at least know how to edit video from the command line is one, automation is, even when you're doing video editing, lots of times videos are very repetitive when you're doing different projects. Example when I'm doing home videos or even wedding videos. I used to do weddings. I still do them here and there. And they're all pretty much the same. I have a digital camera. I use a Canon T3i right now. I film my video clips. I don't film more than I want if there's a clip I take that I know I don't like. I try to delete it right off the camera right away. That way, when I get home, I can drag and drop the videos into my editor if I'm using something like Kaden Live. And I don't have to go through and delete them then. I can drag them to the timeline. They're usually in the order that they should be in. It's not like a movie movie where you may film things out of order. Home videos and weddings, the order you film it in is pretty much the order it should be in. So automation is something you can do from the command line and you may save you some time. If you're going to drag and drop all the videos clips to the timeline, add fade effects, maybe adjust the brightness and contrast, maybe adjust the speed because wedding videos I like doing stuff in slow motion, I can put all that in the script before I go and film it. Get home, go into that folder, run the script. It will take each video clip, fade them out at one second, maybe adjust the colors, maybe add a vignette and save it to a file. I'm done. All I had to do was type the one command. So also another reason, I forgot it's number two reason that you may want to learn how to work this is you may want to create a program like Kaden Live. Maybe you don't like the way Kaden Live is set up and you're gung-ho enough to go and make your own. Well, Kaden Live uses a back end of a program called MLT. It's a framework for video editing. Kaden Live isn't the only video editor that uses it. OpenShot uses it and if you go to the MLT website there's a list of probably ten video editors that use MLT as a back end. We're going to be using MLT but we're going to be using also a program called Melt to go along with MLT which is kind of a shell front end for MLT. I've done tutorials in the past on doing basic cutting of videos, resizing of videos, using FFMPEG and we're going to be using some FFMPEG in this series and in fact in this tutorial today we're going to be using FFMPEG. And that's great. FFMPEG can do a lot of stuff when it comes to resizing, cropping, trimming the video, converting the video which is what we're going to be doing today. Not that great for effects which MLT will let us do. So MLT will let us see the video live before we save it to a file. So here's an example, I'm in Kaden Live here, let me try to add a vignette effect to all these videos here and smooth it out to about there. So let's say, you know, I was able to do a vignette effect with, oh I only edited that for that one, but anyway, a vignette effect in FFMPEG, FFMPEG or M-encoder however you say it, whatever you do to it you have to save to a file as far as I know before you can view it. So kind of like in Kaden Live here I can scrub through this and see the video live without having to save anything and MLT will let us do that from the command line too from the shell. So basically we can write our script to show us what the video is going to look like before we save it to a file. Because it looks good, click OK, type Y, yes, whatever, and it will save it to a file, which is great because there's nothing like spending 20, 30 minutes or an hour rendering out a video just to find that it doesn't look right. So basically we're going to use Melt here, here's an example, I'm going to hit list, we've got a number of videos in here, these are the original video files off of my Canon T3i, they're MOV files, they're high definition, 1080p, 30 frames a second and to play them all together as if they were joined, which I know you can join files with FFMPEG and M-encode, but as I said MLT will let you preview them all joined before you actually join them in a file. So I'm going to use Melt and all I'm going to do is say melt and give it a list of the files, in this case I'm just going to do all of them, and it will start playing it. So here's a clip with my family a few months ago before my daughter was born to have an ultrasound for people to see whether it was a boy or a girl, and so this is what they looked like during that, and now you'll notice at the beginning of each little clip there it really looked crazy for a third of a second, maybe 10 frames, maybe 5 frames, but it was definitely noticeable, and that's something I wanted to point out, because I'm currently running Debian Unstable, I'm running Debian CID, so the software that I'm using is not stable, so MLT and KDY are not necessarily stable versions, in previous versions what I was going to expect was an older version of KDY and MLT, I did not have this issue. When I went to the unstable, I started having that issue, that's part of the problem of working with unstable software, you get the newest but it's unstable, so hopefully if you guys are working with something like Linux Mint or Ubuntu, you're not going to have that issue or a stable version of Debian, not a big deal, because there's a simple solution for it. That little pause only happens with certain video compression, certain video format and codecs. In Kden Live what I've been doing, we go to file, transcode clips, I'll grab a bunch of clips here, and you have these profiles preset, I'm going to do 1080p, 30 frames a second, 220 megabits per second, this will transcode them to another MOV format that MLT loves, has no problem with them, it's a great format, I don't know if any video loss doesn't take long to convert them, it uses FFMpeg to convert them, so it's an extra step but it solves the problem, also even if you're not having that pausing problem, it might be good to convert to this because it might cause MLT to not lag at all, because MLT just works with it better, a little bit less stress on your computer, so if you're having any type of issues like that, try converting them, and that's what we're going to do today, you could use Kden Live just like this but hey, it's using FFMpeg and it tells you exactly what you need right here, so we'll copy that, we'll go back to the command line and what I could do is FFMpeg and then I can say dash I and then the input file will say, we'll do that one, right there, and then I can paste in what I had from Kden Live and give it a new output of new video or new dot MOV, sorry my, I was overriding the text there, and that will create a new file that MLT works great with, obviously I have a number of files so what we're going to do today is we're going to write a script that will automate all that, put the new ones in the file for editing, this is pretty much what I do, I stick the SD card from my Canon camera into my computer, I run this script, it basically, or a similar version of the script that takes the files that I had recorded that day, puts them onto my hard drive but converts them as it's moving them to this format, so real quick I'm going to create a file here, I'm going to use Vim as my text editor and I'm just going to call this MLTconvert.sh, going to make it a bash file so I'm going to say bin bash on my shebang line here, let's make a folder to put all the converted video into, so make directory, we'll call the folder edit, because it will be the videos we're editing, then we're just going to do a for loop, so we're going to say for i in all the MOV files in this folder, and I'm going to do this so I don't forget, and then we're going to say ffmpeg-i, and then our variable for our input file, we will paste in the command from kdenlive, and there were other options in there but this is the one that I normally use, and then I'm going to save the new converted video to the edit folder and give it the same name as the original file. Now in this case, we're converting to an MOV and from an MOV, so that's fine if you're converting from like an AVI file, just put .mov in here to make sure it converts it to an MOV file. Also as you can see my video is 1080p and the frame rate is 30 frames a second, if your original video is only VGA quality, wherever change the resolution, so you're not making big files because you're not going to up the quality, keep the quality the same, save yourself some disk space. But now that I have that done, I'm going to save that, make our script executable with changemod plus x and that file, and then we will run that file with .mlt-convert and it will automatically start converting all those videos and putting them into that folder. So in the next tutorial, I'll show you the output of that, we'll start linking videos together, I'll show you how not to just preview but save videos and we'll go from there. Hopefully you're finding this useful. A lot of people may not care about doing this and I know that, but it's something I do regularly with a lot of my videos and it saves me time, so I thought I'd share it. It's also good, another reason, well I'll go, I don't want to talk too much in this tutorial. Please visit my website filmsrightcris.com, that's Chris of the K, there's a link in the description of this video. If you're not interested in video editing I have got plenty of tutorials up, watch those while we're going through the series, by the time you're done watching all those, maybe we'll be on to a different topic. Also while you're at my site, if you like my videos, there is a donate button and I just want to thank everyone who has donated and anyone who will donate, I do appreciate it, helps the site keep going. And I just want to say I hope that you have a great day.