Good afternoon and welcome to the Green Mountain Care Board meeting. The first item on the agenda is the Executive Director's Report, Susan Barrett. Thank you. Thank you, Mr. Chair. I have a couple of scheduling reminders. Folks should know that our schedule is located in our public meeting section of our website but wanted to call out that on Monday, July 20th, the board will have its first rate review hearing and that's Blue Cross Blue Shield of Vermont. That's starting at 8 a.m. And then on Tuesday, July 21st, we will have the MVP Qualified Health Plan Rate Review hearing. Both of these meetings will be online through Microsoft Teams. And then in addition, on Tuesday, July 21st, starting at 4.30 and going to 6.30, the board will be holding a Qualified Health Plan Rate Review Public Comment Forum. And again, that will be held via Microsoft Teams. The information on how to access that information, again, is on our public meeting section of our website. I'd also like to remind folks that these rate cases are open for public comment. And if you click on our public comment section of our website, you can provide comments to the board on these rate cases. And that is all I have to announce. I'll turn it back to you, Mr. Chair. Thank you, Susan. I'll turn it back to you in a second for the purposes of taking attendance. But prior to that, would some would like to make a motion of the minutes of Wednesday, June 24th? Still moved. Second. It's been moved and seconded to approve the minutes of Wednesday, June 24th without any additions, deletions, or corrections. Is there any discussion? Moving on, all those in favor signify by saying aye. Aye. Any opposed? Okay, Susan. Yes, and I'm looking at the list. And I don't, maybe I can get some technical assistance from Abigail here. So at the bottom, they're just phone numbers. After Spencer's name, there's just phone numbers. Would you like me to call off the last four digits? Would that help you? Why don't you do it? Because they're not showing up on my screen for some reason. You have to hit more. There's a little more link. I don't see those. I think you're going to have to do my job, Kevin. I'm sorry. Okay, 5,001. If your phone number ends up with the last four digits, 5001, if you could introduce yourself. Hi, it's Julia Shaw with the healthcare advocate. Thank you, Julia. 8703. Mike Del Treco. Thank you, Mike. 8869. Toby Howe, MMR. Thank you, Toby. 4534. Walter. I didn't understand it, you. It was Walter. And I did find the numbers, but. Okay. I got this one under control. Walter was checking in. 505. I'm calling CVM Medical Center. Thank you. 6376. Mord-Walterman. Thank you, Mord. 0043. Becky Rondofsky. DRM. Thank you, Becky. 8461. John Olson. Head office of rural health. Thank you, John. 5835. 8461. John Olson. 8461. 8461. John Olson. 8461. 5835. I guess that's Abigail. 2177. I think that might be our office. Yes, it is. Thank you. Okay. 3212. Kathy Mahoney from the General Advisory Committee. Thank you, Kathy. 8888. I believe that's Jeff Hebert. Thank you, Jeff. 5252. Rebecca Copan, Blue Cross Blue Shield. Thank you, Rebecca. 9806. Mike Fisher. Thank you, Mike. I think that's all I have for phone numbers. Everybody else has a name attached to it, I believe. So at this point in time, we're going to go ahead, whoever spoke, I'll take it as an accidental speaking then. At this point in time, we're going to turn the meeting over to Lori Perry and David Glavin and Lori's going to walk us through the health expenditure analysis report for 2018. So whenever the two of you are ready, take it away. Thank you. We're ready. This is the 2018 from our healthcare expenditure analysis and the topic that we will be covering air and introduction, the summary, and then the 2018 Vermont resident analysis, the relationship to the total cost of care, the spending and growth, and how Vermont is compared to the national health expenditures from CMS, the Vermont provider analysis, then the revenues received by those providers and the growth, the hospital revenues, the migration of hospital inpatient discharges, then we compare the resident analysis to the provider analysis, and we also have projections for the resident analysis and provider analysis for 2018 through 2020. Then the appendix will show you some of our sources and methods and other tables, and then we'll also have the Tableau presentation that David Glavin will be presenting for you. Excuse me. One second. Sorry about that. The expenditure analysis has been around since the 1990s, but recently the current statute is 18 VSA, 9375A, and 9383. The report examines trends in spending and sources of funds, analyzes broad sectors, including hospitals, physicians, mental health, home health, and pharmacy, and also analyzes payers such as Medicare, Medicaid, commercial plans, self-insured employers, and HMOs or health maintenance organizations. We also quantify the spending for services for Vermonters within Vermont, having services, and also for out-of-state patients having services within Vermont. We compare Vermont data to the national health accounts, which are with the Centers for Medicare and Medicaid Services, which is CMS. We use CMS's health consumption expenditures, which are a subset of the national health care expenditures, because Vermont doesn't monitor the research, pictures, equipment, and investments in health care that they're represented in the NHE. Vermont residents' spending grew 1.9% in 2018. This was lower than the increase seen in 2017 of 3.7%, and this equates to an average annual increase of 3.4% for the period of 2013 through 2018. We saw commercial insurance spending increase 1.7%, and that was mainly seen in the hospitals, prescription drugs, and other unclassified services. Medicare spending increased 5.1%, and this was in home health, nursing homes, hospitals, physicians, and drugs. Medicaid spending increased 1.1%, mainly due to increases in mental health and other government activities, other professionals, and home health. There have been a payership over time from 2010 through 2018. Commercial insurance decreased from 38% to 33%, out-of-pocket decreased 14% to 13%, but Medicaid grew from 24% to 27%, and Medicare increased from 19% to 24%. We also want to make note for your reference, is this our, with the state of Vermont in the circle, this represents resident analysis, and you'll see that through the whole resident side of this presentation. Then we compare Vermont expenditures to the United States, and as we mentioned, Vermont grew 1.9%. The United States spending grew 4.8%, and this was an average annual increase of 4%, excuse me. This was higher than the 4% realized in 2017. We also look at per capita spending, and Vermont was 9,995, or an increase of 1.4% over 17%. The United States increased 10,640, and Vermont's share of health care for the gross domestic product was 18.8% this year, and the United States was 16.9%. Vermont health care providers received revenues for in and out-of-state patients this year, and that increased 3.2%, and that was an average increase of 3.4% for the period 2013 to 2018. Hospitals grew 3.5%, and this includes hospital-employed physicians. We also saw increases in other licensed professionals of 11%, home health of 9.5%, independent physicians of 3.2%, physician and DME 2.2, and drugs of 1, but we did see a decline for nursing homes of 2.3%. And then this symbol at the bottom of this slide with the P for Vermont means that that is our Vermont providers giving services to in and out-of-state patients. Now we're going to the resident analysis, but first I wanted to let you know what the relationship of the resident analysis is to the total cost of care. The total expenditure analysis measures expenditures on a larger scale in its comprehensive level compared to the total cost of care as described in the All-Pay or Accountable Care Organization model agreement. The expenditure analysis resident analysis estimates all Vermont residents where the total cost of care is a subset of this resident analysis, and it excludes certain populations such as residents without insurance, or they're covered by the federal employee health benefits plan. The expenditure analysis provider estimates includes all populations receiving services in Vermont, regardless of where they live. The total cost of care concentrates on Vermont residents only. The expenditure analysis resident and provider estimates total expenditures. The total cost of care is limited to claim payments for the types of services covered by traditional Medicare or non-claims payments related to direct medical care. Total cost of care does not include retail pharmacy. We also wanted to show you how it relates to each other, so the resident spend on the expenditure analysis is equal to about $6.3 billion. The total cost of care with the All-Pay model is only 46% of that or $2.9 billion, and one care Vermont budget of the total cost of care is $609 million. We just wanted to make sure that everybody can understand this relationship. Also, the ACO represented 10% of the total spending on the resident analysis. We, for this analysis, we look at 2013 through 2018, even though we have data way back to 91, and we always look at the payers, out-of-pocket commercial Medicare, Medicaid, and other government, which is local and federal. And then how do those payers spend on provider and facilities, like hospitals, physicians, and nursing homes?  By the way, if there's any questions at any time, feel free, and if I can't answer them right now, I'll get back to you as soon as I can. And I would just ask board members, if you do have a question, to click on the hand so that we'll know that your hand is raised. The spending for the resident analysis from 2010 to 2018, this was an average increase of 3%. So in 2010, it was $4.9 billion, now it's $6.3 billion. And as I mentioned before, the change between 17 and 18 was 1.9%. This is showing the in-and-out-of-state spending for us as residents, so we can go to Florida, we can go to New York. This is incorporated in the resident analysis. And these are all the services and the full dollars that were realized this year. So we were seeing most of the increases in spending equated to $114.1 million. And most of that was seen in drugs and supplies in the commercial insurance and out-of-pocket. Possible showed increases in commercial and out-of-pocket. Mental health and other government activities such as mental health clinics, home and community-based services were reported in Medicaid. Home health care increased in Medicare. Physicians increased in Medicare and out-of-pocket. So this is just the larger increases that we're seeing in the analysis this year. Then we also look at the payers, how they rack up. So for instance, the Medicaid payer makes up 27% of the spending and then 22%, excuse me, 25% of the enrollment. And commercial is 33% of the spending and 50% of enrollment. So we also, as you can tell with the enrollment, it doesn't account for out-of-pocket. So all of us, like in Medicare or commercial, would be having some out-of-pocket. And then this is another look. Where did our spending come from? Who paid for it? So health insurance from Medicare, Medicaid and commercial made up 84% of where the funds were coming from, but they spent it on the hospitals, physicians, drugs, mental health and other. And this is looking at commercial insurance and commercial insurance spending increased to $2.1 billion or 1.7% increase. This was $33.4 million. And the increases were seen in hospitals, drugs and supplies and other unclassified services. But we saw decreases in physicians, and net cost of health insurance and other professionals. The in-state spending for commercial insured patients remained at 75% to 76% in the last couple of years. And commercial insurance enrollment decreased to close to 315,000 residents or enrollment. So, Laura, I'm going to interrupt you because Susan texted me to say that Robin has a question. I never saw her hand raised on my screen, but Robin, go ahead. We can go back to it. It's a few slides back now, so don't worry about it. Okay. All right. So, this particular pair includes comprehensive major medical insurance, self-insured, dental, long-term care insurance, workers' comp, Medicare stuff, limited liability insurance. And the enrollment for commercial insurers was decreasing as the other two pairs of Medicare and Medicaid increased. And I'm going to go next to the Medicare pair. And this one increased 73.3 million, or 5.1% to a total of 1.5 billion. And we saw increases in home health, possible physicians, drugs and supplies, but decreases in other unclassified dentists and admin and net cost of health insurance. Other beneficiaries, this was a little bit of a surprise, in 2017, 68% was in state spending and 73% for 2018. And then Medicare enrollment increased 136,567, or 2% from last year. Because of our aging state, Medicare has continued to increase an average inner percent of 6.2% between 2013 and 2018. And in 2012, spending was 1.1 billion, now it's 1.5 billion. And we use V-Cures for this particular source to find the spending on Medicare. And for the last couple of years, we've used V-Cures for the last couple of years. And the ACO accounts for approximately 385 million as Medicare revenue for their calendar year 2018. The Medicaid increased to 1.7 billion, or $18.3 million, 1.1%. We saw increases in mental health and other government activities, other professionals' home health. There was decreases, surprisingly, in hospitals, drugs and supplies, admin and net cost of health insurance. The in-state spending for this particular pair remained at 85% to 86% for the last couple of years. And Medicaid's enrollment increased to almost 155,000 people, or 3% from 2017. The information from Medicaid, we received that from the Agency of Human Services, and they reconciled that to the CMS Global Commitment Waiver. They also report on managed care organizations and the CHIP program, long-term care. And then V-Cures is used to support the claims and non-claim spending. From the resources that I have, the $70.8 million from the ACO was capitation payments for Medicare, Kate, and then that was based on the state fiscal year. And in Medicaid, there is, like we mentioned, mental health and other government activities. I thought I'd give you this slide to show you all of the type of services that are included in that particular category.  We have more, if you would like it, just let me know. We also, there's a big category that's called net cost of health insurance for all the payers, and this is the difference between the premiums earned and benefits incurred, and it includes premium taxes, admin costs, net addition to reserves, and profit and losses. This category kind of is one of the major factors in the swings in the growth by payers and in commercial in particular. And commercial, they also have to pay the ACA fees to the federal government every other year. So that can sometimes account for the swings. In the commercial insurance, they have the two components. It's the admin and then they have change in surplus where Medicare and Medicare do not. We can explain more at another time if anybody needs more information. I have this slide every year to show the percentage of what private payers like you and I will pay for provider services such as dental and vision and durable medical equipment versus other services like home health and nursing home, which is usually funded by public payers. Lori, this is Robin. Can I, before you jump in, I just... On the previous slide, if I'm recalling correctly, we include... One thing that may not be intuitive is we do include state employees and teachers, for example, under commercial insurance, right? Not government funded. That's correct. Okay. I just wanted to make sure I remembered that right. Thank you. Now we're transitioning into comparing the month spending to the United States. And so I wanted to go over our resources. We want to emphasize that when researchers and others compare United States to Vermont and other states, they use the state of residence or state of provider data from CMS. And that is produced every five years. And the most recent was 2014 published in 2017. They get their estimates from census data. And if that's not available, they get it from other population data, wages, employment, and IOS business receipts. Our data is small compared to the United States, and the United States works in thousands of dollars. So ours is more precise and Vermont rich. So I'm just... We'd like to sometimes tell people to be cautious when they're comparing Vermont to the United States, because we're so small, it's hard to compare. We use the Vermont... We use the health consumption expenditures when we are comparing Vermont to the United States, where the United States would normally use national health expenditures. And so we use health consumption because it includes personal health care, administrative net cost of insurance, and public health activity. We don't use the NHE because that also includes the investments in research structures and equipment. This slide is showing you the different comparisons where Vermont is not included under NHE, where you include yourselves under HCE, and then we also have the personal health care. The United States increased 4.8 percent in their spending, where we increased 1.9 percent. And the per capita for the United States increased 4.1 percent and Vermont increased 1.4 percent. Our share, health care share of gross domestic product or gross state product is 18.8 percent, and the United States is 16.9 percent. I included this slide because I was asking the pastor of the history of Vermont statistics compared to the United States. If needed, we can report back to the early 90s if anybody wants his data. The changes in Vermont's administration and net cost of insurance in 2015, 2016, and 2017 were significant enough to cause the swings in the inner percentage of total spending. Again, this may be caused from the ACAPs or insurance cost changes from year to year. But as you see, if you can see the trend line, Vermont is trending downward where the United States is trending upward. And this is, again, we're comparing ourselves to health consumption expenditures. And the per person or per capita growth, we are increasing at 1.4 percent for this year, and the United States is 4.1 percent, and we're trending downward. For gross on average for 2010 to 2018 is 3 percent, and the United States is 3.7 percent. And this slide is just showing the dollars. So Lori, we've had a request from someone following along on the pages. If you could just, as you switch slides, say which slide you are on, so those that are not using the screen, they're just using the actual off the website. Okay, on slide 27, that was the per capita per person slide showing the dollar amounts from 2010 to 2018 for Vermont and the United States. Thank you, Kevin. Slide 28 is showing the gross domestic product and how Vermont has compared itself to the United States since 1996 to 2018. You can see spending in Vermont, we have been pretty high. And for the time period of the last 10 years, it's been about 18 to 19 percent of gross state product. It dropped a little bit in 18, and so did the United States. We have generous Medicaid programs, and of course our aging population can account for some of this growth. Slide 29, I'm transitioning to the provider analysis. So again, we look at 2013 to 2018. In this look, usually we have provider direct reporting telling us how they got paid, who paid us, what payers, Medicare, Medicaid and commercial. And it's different from the resident side because the resident side is payers, commercial Medicaid and Medicare telling us what they paid for. So the revenues received by the providers grew from $4.8 billion in 2010 to $6.4 billion in 2018, and this was an average increase of 3.7 percent. 2016 was 3.2 percent, 2017 was 3.3, and 2018 is 3.2 percent. This was mainly dominated by the growth in the hospitals, which makes up about 47 percent of the revenues. Slide 32, when we talk about provider revenues, we're talking about in and out of state patients having services within Vermont. So this particular slide is trying to show you the total spending for each of the provider categories and what is the percentage of the total spending those categories make up. So our hospitals, we have strong hospital data because we regulate 14 community hospitals. We also have data from the Veterans Hospital in White River, Vermont Psychiatric Care Hospital in Berlin, and the Brattleboro retreat. We also have direct reporting from nursing homes and home health and hospice. The other provider services are from a variety of sources like drugs and supplies from Kaiser, and this is without rebates as we do not have reporting on that. Physicians are net of hospital employed physicians because we report that within the hospitals, the other provider categories are estimated similar to the physician revenues, which is basically taking physicians that are derived from the economic census and the N.H.T. And then we use beacons for reasonableness. The mental health and other government activities category is the same as the resident, and the provider analysis, as you will notice, does not have admin or net cost of insurance at all when we're comparing it to the resident analysis. Slide 33. So we're showing that the revenues increase 3.2% this year, and this was for the largest thing as we've been saying in the hospitals, and the hospitals include hospital employed physicians. The other categories were the licensed professionals of 11% and home health with 9.5% independent physicians at 3.2, vision 2.2, drugs with one. But we saw a decrease in nursing homes of 2.3. This slide, we were able to get information from the Department of Health, their 2018 physician census, and they reported 2,473 physicians were practicing in Vermont, and there's 1,368 are full-time equivalents. And of that is about 82% or 1,132 are employed in the hospitals. We also like to show that the hospital's physician revenue has been increasing from 35% in 2010 to 51% in 2018. We're seeing that the hospitals are employing more and more physicians as the sustainability of independent physician practices are getting harder and harder. With technology and the administrative burden from the payers, some of the physicians are leaving independent practice besides some of the physicians are retiring. Slide 35, this information is from the hospital discharge data set, and we were sometimes in our hospital budget, some of the hospitals mentioned that they were seeing more and more out-of-state patients through the years, but based on this information, the state as a whole has been remaining constant at 13% for the last couple of years. We wanted to show you a little bit of changes between hospitals that we regulate between 2017 and 2018. Slide 36, we're comparing the resident analysis to the provider analysis. If you look closely under the provider services, you'll see hospital positions and the resident analysis is zero. The provider side is over $402 million. That's because that's hospital employed physicians that are seen in the hospital budgets that we regulate. Dropped in supply on the resident side is less than on the provider because it's net of rebates. And the provider side does not have admin and net cost of health insurance. That's a major reason why they're so different. But they're also, as we've mentioned, different populations, different patients. We are tasked with also having a projection of resident and provider spending. And this year, we have directly 18 expenditure analysis that we just showed you. And then we're projecting 2019 and 20. And the main increase was seen from Medicaid. And we got that direct reporting from Medicaid of 3.2% or overall 3.2. But Medicaid is showing an increase of 3.4%. The next slide is 38. This slide we have provider revenues increasing 3.2% from 18 to 19. And this is mainly driven by the hospitals and which make up 47% of the total revenues. We have direct reporting of Vermont community hospitals for the period 2018 through 2020 because we monitor their budgets. And then the rest of the projections are based on NHE and Vermont trends. Don't be like 39 is their appendix to let you know there's more analysis and sources. I can go through this pretty quickly because then we would like to hear from David Glavin about Tableau. This is the matrix of the information I showed you previously. This is slide 40. And it's showing each payer what they said they were spending on for like other professionals, other unclassified positions and things like that. So this is the payer telling us what they paid or spent on. And then we also broke out commercial insurance to show you self-insured, Blue Cross, TVHP, MPP, Worker's Comp and other private. Slide 42 is provider analysis similar but this is where the providers are telling us how they're being paid. Who's paying them commercial medicated Medicare? Slide 43. This is enrollment in our different payer categories. So we have rich data from the annual statement, supplemental statement report. And we also have it from VQRs. We also have data from Vermont Health Hold Health Insurance Survey. So very rich data that we've been using for many years. And so this helps us to understand where people are enrolling and the changes from year to year. So the other thing we want to caution is because of our sources, sometimes people can be counted twice. And that's why we have that note towards the bottom of the slide. And then 44 is my method and sources and technical notes. And we also want to let you know that 2017 expenditure analysis was revised because we had better Medicare data. And so when that's revised, we also revised the out-of-pocket. And also out-of-pocket is a pretty complicated calculation using Vermont data, Medicare allocations, commercial allocations and also the Vermont Health Hold Health Insurance and census data. So it's just not from one place just to let everybody know that. And then I would like to introduce David Glavin for the Tableau Interactive Visualization. Hi, everyone. Hey, David. Are you okay? I'm just going to go right off and share my screen. So in conjunction with Lori's annual report, we developed a tool with the analytics team's developed a tool. And this has been around for about three years. We developed a tool that summarizes some of the information that she's presented within the expenditure analysis. And Lori, you're going to have to remind me of this, but we only have a resident spending only perspective. And I can't remember the reason why we don't do the provider. So if you could step in and remind everyone why we can't create that. I think because the categories could not be relatable sometimes. Correct. And we were trying to do the relationship. And if you found it, made more sense to the total cost of care. And most all of our work is on the resident side. So as a result of that way, this particular visualization is specific to the resident spending. And so it does not include the provider perspective analysis that's included in the entire expenditure analysis report. So first of all, how do we access it? And there's a couple of ways to access the report. The permanent methods are obviously going to be through the board meeting information. Abigail has included a link in today's agenda. So if you just select that, that will launch the Tableau public website, which is where we have several of our visualizations house. And I can actually show you that real quick here. So we have a few other visualizations at this website. You can Google this as well to Google Tableau GMCB Green Mountain Care Board and to get to the site. And in here you have the expenditure analysis report to do in addition to a couple of other reports that we've available. And we're slowly populating this. I shouldn't even say slowly. That's speeding up. We have a few more that are cooking in the oven right now that should be up and running within the next four to six weeks. So anyways, let me show you a couple other ways of accessing. So from the Green Mountain Care Boards main page, if we go to the research and reports link, and then the expenditure analysis enrollment and market share reports. This picture over here and there's a little message here that also says click on the picture, but this picture over here will launch the link to the, the launch the URL to the visualization, the interactive visualization. And then the last location is to the data and analysis link. And then we have a data data reporting link. And on that we scroll down, we have several public reports. And within here is the expenditure analysis as well. And then that will also launch the tool. So the tool is available without, you don't need the, you don't need software. It's like I said, this is interactive and it's, it's just URL based through a web browser. So a couple of limitations on the web browsers. And this is most likely due to a tour for with the Microsoft visualization tool, but Tableau, which obviously is a different company, doesn't play well with Microsoft products. So if you're going to use a browser to, if you're going, when you use your browser to launch the visualization and kind of go through and play with it, we recommend using either Google Chrome, or Fox or Safari to do that. As it doesn't play, the software does not play very well with Microsoft browser products. And like Lori said, if you have any questions, feel free to just cut in at any time. And I'll just try to keep this brief. I just want to give a high overview. I think she's gone through the analytics, analytic elements of it. I just want to show you the tool itself, a couple of features with the tool in terms of download capabilities. And then just to kind of show you the high overview of the visualizations. And at some point if you guys are here, anybody that wants to go in can take a look at it. So on our second tab, so you'll notice that we have a series of tabs across the top here. This is going to take us to the different, what we call dashboards, which has combination of graphs and interactive visualizations. So on this first page here, we have a definitions page just so that we can be clear about what our population descriptions are, the methodology, and this is a very high view of the methodology, our data sources. But what's most important to page is that we have a couple of hyperlinks here, one that will take us to the current expenditure analysis report. So if I click on that, click on that, it'll take you to the report that Lori just presented. And the second one takes you to the more detailed manual. So if you have any questions about a particular graph or something out of the report, this gives a much more deep public description of the methodology and sort of the backbone behind the process that Lori is developing. So that's the, I think the most important element from this. If these are sort of high overview briefs of the data source population and the methodology, but if you want more specifics to the current 2018 report, the hyperlink is here. And so the real methodology and more detail elements are in the manual down here. So the first view that we have is what the residents spend over time. And these views were developed and we had a couple of our board members a couple of years ago helped develop these views and select some of the key graphs out of Lori's report. And then we tried to create them in a, put them into a visually aesthetic format so that you could get lean information based on just looking at visualizations and not digging deep into the report or looking at cross tabs, series of cross tabs. The one highlight I want to mention on these, there are a couple of things I want to mention on this page is we have some highlighting elements here. So if you actually select on one of the payer types, it will highlight that graph on the right hand side. And this is giving us the percent change from the previous year. So one thing to note is that if there's a, what's called a tool tip. So as I hover over this graph, you'll see a little box up here that says 9.5% change. And it gives you detail with respect to which year that changes. So this is, there's a 9.5% change from 2014, which doesn't appear on this graph, but it does appear on this graph. So you can select multiple payer types by either holding the control bar and selecting another payer type. And you'll see that they highlight on the corresponding line graph. If you select again, that will clear the graph. So you have to click a couple of times on it to get the graph to clear. There's also a reset tab. So if I have these collected over here, if you go down to the lower right hand corner, there's a reset. This reset tab will reset the entire workbook back to the original settings. So if you make, and you'll see in subsequent views that there are, you can filter by year and things like that. If you filter by year on another page and then you reset, it will reset the entire workbook. So you'll have to go back and if you, if you think I'll, you'll see that in more detail. I know it's one of the other pages here, but I just want to point out that reset. So if you are uncomfortable with that, so you can't get this to deselect, go down and hit the reset tab here and it will reset the page for you. You can also correspondingly select any one of these graphs, any one of these line graphs, and it will highlight the spend on the, in the bar graph. And then one thing I also want to point out, that we sometimes get questions or in there, sometimes confusion about, for some first time users about like, well, what is that? We don't understand why. We don't understand why. Where is this minus three, minus 3.9% coming from? And if don't, I think a lot of people end up looking at, these are the totals for each year across the top here. The minus not 3.9%, the 6.8% is actually within the commercial group. So if we look, we see that there was a decrease up from 1.92 billion in 2014 to 1.8.5 billion. In the commercial data group in 2015, that's that minus 3.9%. So that's what that is referencing. It's not referencing the total increase over time. Those increases are represented up here. So the actual total values percent changes are highlighted in this table up here. So any questions about that one? And also just pay attention to the notes. When you guys are in here, I put a lot of notes into kind of help define. So what is involved? What is in the commercial bucket? What is in the other sources bucket? So the definitions will be located in some notes or they'll be located in tooltips, those little bars that kind of pop up as I move forward. So that's what we're going to look at. So that's what we're going to look at. Next dashboard is the private versus government compare. On this one here. I just wanted to point out the. This is the two filters on this are filtering for year. The filter obviously will not apply to the. The expenditures over time. So that's what we're going to look at. So that's what we're going to look at. So that's what we're going to look at. So that's what we're going to look at. The expenditures over time because we're not going to be filtering down to a single year here. The filters by year will filter the government versus provider, the payers breakdown or the spend of government provider or private within each one of the providers. And it'll also change the total expenditures graph as well. So if I select a different year here, we'll see that the graph should update for these two graphs here and the two bar graphs here. And then you get detail within providers, the breakdown of the government and private spending within each one of the provider types. The categories are listed over here. So what belongs to government, what belongs to private? I want to point out this is very important that these two provider types are excluded in administration and change in surplus. There's a note down here that the data source does not allow for these values to be distributed between private and government groups. And therefore we excluded them from this page. So the reason I want to point this out is that you may look at this total expenditure value over here, say 5.51 billion. And I'm in 2015. So if I go back to the resident spend over time perspective, I'm looking at 2015. I'll notice that it says 5.72 million, which is the actual total spend that includes, that includes the admins last change in surplus exclusions. That delta is represented down in this note down here. So it says the missing amount from the grand total for these categories is the 206 million. So that 206 million dollars that gets us up to 5.7 billion for 2015 are located down in this note down here. So just pay attention to that. Don't come to the conclusion that we've missed or left something out here or that there's two different spends. The actual total spend is located on the resident time or you can add this 206 million into the 5.51 billion to come up with that total. And then the other piece to this graph or to this particular view is the spend over time. So the breakdown of these categories, except instead of looking at a bar graph for a specific year, we have the spend broken down over time with the total amount. So you can select on hospitals, for example, and we'll give that hospital private. And if you hover over any one of these individual nodules, you'll see that we have the category and the specific spend amount down to the dollar. And then the next tab is the resident spend by provider. This provides a cross tab with a percent breakdown by each of the providers over time. And then down below we have a little bit more detailed view of each of the provider breakdown into the payer types, commercial Medicare, Medicaid, out of pocket and other government spending. The default setting is for hospitals. And if you'll notice that I have dynamic title. So if you change any one of the years, the year should subsequently change so that you know that you're looking at the 2016 resident spend by provider. And then this is the proportion breakdown within the group hospitals. And the tree map over here gives a visualization in rectangles of that proportion. You can give you a quick look. All right, commercial looks like about two thirds. Medicare and Medicaid is there. I'm sorry about half Medicare and Medicaid represents about another third or there are these other four categories represent another quarter. And then that breakdown within those. The actual specific amounts can be found by hovering over each one of the payer types. And that will give you the exact expenditure within the hospital group. To switch the type of provider, just click on one of the bar tabs. And that bar tab will swap out the tree. And you'll see that you get 93% for Medicaid here. And if you hover over this one, because there's not enough space to actually put the other government valuing here, you hover over that. And the tool tip should provide you with what payer type that is. Now, because of that, I also want to point out, I think it's dental. It's a good example. 2016. Yeah, so your nose over here, I have two very tiny little slivers that represent about 0.1%. So that's one of the sort of drawbacks to this. You're really getting a high overview of the spend within each one of the provider types here to give you the main spenders. But if you can actually see those details, if you hover over them, they will show up and you'll see that you do have those point that those missing value, or what appears to be missing dollar values that are represented within them. So with these interactive visualizations, they are interactive. So I do encourage people to kind of play with them and pay attention to a lot of the tips that we've put inside of them. Like I said, if you hover over a particular bar here, you can get the exact spend instead of the spend in billions of dollars. We get the exact spend here, and then also a little note to click on this bar if you want to highlight that in spending and kind of give us just a graphic view of what's the breakdown within that other profession in 2016 category. Like I said, if you need to reset this, just hit the reset button. It'll reset this. But like I said, it'll also reset your other visualizations in each one of the previous steps or any of one of the dashboards. Let's see. Okay. And then the last one I want to show in detail is this resident expenditure analysis Crosstab, which has our providers by payer type breakdown. And I really like this just because it was tricky to put together. But we also provide the year selection filter. And also, if you click on any one of these value types, it will break down the percentage of the spend either by the payer type or you can do it across and it will be by payer type within each one of the provider types. So just another feature that we've added in. I think this was added in last year and I really like this as well too. And also one thing to point out is you hover over this. You'll see this message come up. It says select the plus bar above hospitals category and to the left of the tone. So you'll see this plus bar appears over here. If you click on that plus bar, that brings up a little bit more detail of the sub-provider types within each one of the main provider categories. And this mimics one of Lori's Crosstabs that she has within the report itself. So this also provides that detail as well here. And these percent values across and down also will work with that as well as the year filter. And any questions? Okay, one last thing. So first of all, I want to talk a little bit about just a couple of the download features that people can use for this. So first of all, we have the data for downloads and the data set that I use to build this. This is going to be changed. And I want to point this out on... I'm going to be changing this final tab just to allow for a CSV or an Excel spreadsheet. You'll be able to click on that tab like this and it'll download just a CSV directly. I think it'll be easier for folks. So if you come to our website, you'll see the expenditure analysis vis. I'm going to be adding another tab in here to allow for download of just a CSV slash Excel file to be able to access that data a little bit easier. I do want to point out that you can also do that from this particular page here. And that is located on this download button. And I hope everybody can see this. There's a little download icon in the lower right hand. Not to be confused with this one up here. I spent time with Tableau talking about this. This button up here will download the entire workbook. And so anybody that has the software can download this entire workbook and open it up in the software and be able to manipulate, change some of the visualizations, access the data that's within there. To download the actual data itself, and there's several other options that you're allowed with here. This download icon down here will launch this window and you can download an image. The image will just download the current image or view that you have up. So if I have, so for example, if I'm going to download an image of this particular page, it won't download each individual image of these graphs. What it will do is download the entire dashboard image. So that will open up and then you'll have a dashboard. And that image can be used. It's important to have one. Somebody wanted to use that or embed it on a webpage, et cetera. I think the easiest tool is, I'm going to go back to that. I think the easiest tool to use is this PowerPoint tool. And what the PowerPoint tool will do is allow you to, when it says from this dashboard, it means the specific page that we're looking at right now. If I click on this, it will allow me to pick any one of these four graphs that are located on this page here. So I can select all of these and it'll download a little PowerPoint presentation. I encourage people just to play with this. I'm not going to go into more detail than that, but I just want people to know that there's the capability of actually downloading the entire workbook as well. All of the visualizations and all the work and it'll download an automatic PowerPoint presentation with each one of the graphs in there. You'll also notice this is one of the graphs that's a note that's put in there. So it'll download anything that I've developed into the visualization. But just another nice feature that's accessible. And then like I said, you can also download, let me go back to that data page, the entire data set. So you can do it in two ways. As a cross tab, which I encourage folks to do the cross tab, it'll be a CSV file. So pay attention that the CSV file is not an Excel workbook. So you would need to save this as an Excel workbook if you wanted to create this in Excel. But this is the entire data set that I used. This is the base data set, exactly how it looked when I got it from Lori to build the entire workbook. And so anybody can download this in it. We have, even though the views are limited to five-year views, 2014 through 2018, we have data going back to 2012 available. And then in addition to that, I'm not going to go into detail on the data. This is for more advanced data users. You can download text files and the full data set. And when it says the full data set, if you click on show all columns, this will include every single element that I created building the dashboard. So this would be a little bit more for power users if they want to download the data set in the format that I've created within the workbook itself. So that ends the presentation with regards to our tool and availability of it. If there are any questions, happy to answer them. So a question for either Lori or David from the board. I have a question. Go ahead, Tom. So this is incredibly granular data and congratulations to you all for putting together and for Lori being the backbone of this over the years. As we're going through this, I mean, there were some low numbers that popped up like the 1.9% 2018 over 2017 increase in healthcare spending. And I'm just wondering how hard it would be. I mean, there's some very topside numbers where you take gross spending and divided by the population and you get it per capita number. But how hard would it be to get more granular in that regard so that we could see affordability relative to the Medicaid population? So we have the spending side of Medicaid. Diva has obviously the income side of Medicaid. And is there a marriage there so that we can have more insight into the affordability of Medicare? Similarly, is there a path, which I can't see one, but I'm wondering if anyone's thought about a path relative to affordability of the commercial spend. So affordability is one of our major mantras. And I'm just wondering how this data might be manipulated if it can be a little bit to profile affordability by different groups. We've had that request many times and the concern I have is where do we bucket for a pair out-of-pocket and where do we bucket the other government spending that we get from state and federal? So it's easy to say this is commercial, this is Medicaid and this is Medicare. But where am I going to put uninsured as a population? Where am I going to put the spending for out-of-pocket and other government? If anybody has any ideas, we can try it out. I mean, it's probably just a small percentage change, but I think that that's a great idea to them and we've been trying to think of it. It just doesn't add up, if you know what I mean, to the total spending. But we can do something for you. I have a couple of questions too. Lori, looking at the chart, is there a way to do how much is out-of-state spending for Vermonters and separating any of those charts by out-of-state, the out-of-state spend and the in-state spend and seeing where the changes are? I was able to get that. That's where I was mentioning that in-state versus out-of-state was either 75% or 76% between years. Medicare was like 68 in 2017 and like 73 in 2018. Yes, we can, and I can dive deep for that information if you want, but it would only be that particular bucket. I couldn't do it for the out-of-pocket. Okay. I mean, I don't think, you know, I know we're moving into a busy season with other things, but it would be interesting to see what the trends are for people who are going out-of-state by some of these categories and what's staying in-state and if there's anything we can see from that, you know, so that might be for a future time. Sure. Just one question. When it looked like one of the biggest changes, and I think it was on page 12, was vision and DME, I think went down year over year by 44, I think it was like 44 million. Yet when you look on the other side of it, which was on page 32 or page 15, DME actually was going up slightly. So when we were kind of looking at the differences between the revenue and the expenditures, it seemed like that was an area that had a big change and when I looked at the total spending of that area, it looked like it was only 112 million. So to change 44 million in a year was a lot because of course I like to see the 1.9% in spending, but you know, there's always that disconnect between that spending and the revenue, which was, I think, what, 3.7? I believe most of that was my calculation out of pocket and also taking the allocation from NHE and our Vermont Health Insurance Survey. I was questioning that too, but I didn't have quite enough time to really investigate it. Okay, it just seemed like that was a pretty big change that was down on one side and then on the other side it was fairly flat and on total spending. So, you know, in that 44 million out of, you know, it still was, if that had not changed, it would have been a little bit higher percent in spending change, but... It also depends on what the individual payers were telling me was being spent on that category. Okay. And then one other thing for the future, and I think we've maybe talked a little bit about this before, but the admin and net costs, you know, it sometimes appears like the admin's going down, but it's going down because of changes to surplus and reserves. Right. So, I mean, it's kind of like maybe we should look at admin costs for admin costs and see how that's changing and then surplus to reserves. And that, again, could be for the future, but it just kind of masks the fact that, you know, true admin costs may be going up year over year, and then it's being offset by change to surplus, which is not, to me, necessarily reflective just of admin. Right? That's more probably reflective of claims. Right. And that's why on slide 19, we wanted to emphasize you only see that in commercials. So if you wanted me to just show commercials, like at the bottom of slide 19, it's showing that change in surplus and then change in administration from 12 to the 18. Yeah. Yeah. You're right. Yeah. No, that would be good. Okay. No, it is lots of information. It's always helpful to look through this and it takes a lot to digest. Oh, yeah. Yeah. That's why it's giving it to you just within this last 45 minutes. Yeah. It doesn't tell you what it takes to put it together. And if anybody's interested, just let me know and I can share my resources and data. Yeah. No, thank you. It's obviously a tremendous amount of work and, you know, it gets referred to and a lot of other things. So. Yeah. So thank you for that. That's all I have. Okay. Lori. Okay. Go ahead, Jess. Oh, I was going to say, Lori, first of all, I want to thank you. Thank you. Thank you. And David as well and everybody else who contributed to this, I know it's a monumental task and it's heavily utilized. So I appreciate it. I'm just wondering if you can you go to slide 32 for a quick sec. 32 or 33. Either one of those, I think. Okay. If you want. Sure. I'm just wondering if that's right now. It is. It's perfect for me. Okay. Good. I'm just wondering with respect to healthcare revenues and hospitals and physicians. One of the things that you had mentioned was that hospital employed physicians would be counted in hospital. Right. Is that right? Right. So just wondering, given we've had this shift over the last five or seven years of our physicians moving out of private practice into hospital employment, you know, the slice of physicians is going to look smaller. The slice of hospitals is going to look larger, but it's really just a transfer of employment status to some degree. And I'm wondering, is it possible to slice out of hospitals, you know, the physician component of that so that we can actually see that trend over time and recognize that that's what's happening to some degree. Is that possible? We have, yes, you should see that, at least a slice of it. And on at least for this year for 2018 slide 42, you should see inpatient physician and outpatient physician for our community hospitals. And we have that for as long as we've been reporting it. And we can give you that trend if you want. I guess I was thinking 32 and 33. It doesn't break that out. So, but it talks. So we're talking about hospitals. And that's only a piece of their spending. And also when we're talking about hospitals in that particular slide we were talking about, it included the veterans hospital and the psych hospital. Right. Okay. If you want to get granular, I can. I can. We can talk about it. Yeah. Okay. Thank you. Other questions from the board. If not, we'll open it up for public comments. Are there public comments? Hi, Kevin. It's Kathy. Okay, Kathy. Just a quick follow up on Jessica's question just now and speaking about the physician category. I'm curious as to how you capture our advanced practice folks. They're, I would imagine they're more likely to be employed than the physician. So where do they go? Do they go in the general bucket of hospital expenses or they under a separate provider bucket or, or where are they? It all depends how the census also counts them. So there would be in like the office of physicians and that's basically what this provider revenue analysis is looking at is the offices. So like I just mentioned, if they're a calendar for in the physician office, that's where they would be. If they're in the hospital physician office, they would be in the hospital. Does that help a little? Yes. Thank you very much. And then I had a, another couple of comments on the tableau piece and I wanted to really thank you guys and David, particularly for the presentation. I'm familiar with Tableau and have used it in a few other projects previously. And so I, I totally understand the amount of work and rework it takes to put this together. So thank you. And it has the potential to really inform a lot of decisions that we make. I had a question as an example. So if I click on the, the tab on the Tableau file that says, for example, residents spend by provider. The top spend, as we've said today is in hospitals. And I wonder if there's a way to drill down or is the plan in the future to drill down into hospitals to see, are all hospitals spending at this present rate, which is, I can't see it now in my format, but let's see 2018 it was 36.3%. So do we know that all hospitals, you know, is there one hospital that's 50%, one hospital that's 12%. Are there plans to take a look at that? I'm not sure in Tableau, if you have those percentages in my data, I'm not sure if David, if anybody could download the data and get those percentages, if you open up the hospital category, you might be able to find that. Because I have hospitals, like I mentioned the two psychiatric hospitals, the VA and then our community hospitals. That's the main, a combined total hospital. Yeah, I'm just thinking that that might provide some information where you could look for variation in increases or decreases to try to learn from those changes. Yeah, and those are elements that we can incorporate. You know, if we have the data, we can incorporate those elements into the workbook, the visualization itself, but in this case, it would probably be a different view on a different page, but there would be some relationship between that and possibly build in. Anything's possible. It just is, just take some thinking and some work. Right. Yes, it does. Thank you very much. Thanks, Kathy. Other public comment. And good afternoon, Mr. Chair. This is Susan Aronoff from the Vermont Disabilities Council. Hi. I think I heard Lori about three, maybe four times during your presentation, a reference to something to do with the ACO spend in relation to the slide you were talking about. So there was one point when you said what the residents spend was for Vermont. And then you said some percent, maybe 10 was ACO. And there was a similar reference for the Medicare and Medicaid spend, but I didn't see anything like that on the slides themselves. So I'm wondering if you can shoot me in email or post those references. And if you had some breakout on Tableau or somewhere else, that one could look at these things by, in relationship to the ACO. We could try. The 10% that I was referencing was comparing the resident expenditure analysis and the total cost of care spending and then the one care Vermont budget. And all I did was take that 609 million and compare it to the total spend on the resident side, which equaled about 10%. The other information, I can get it for you, Susan. The other information is not necessarily comparing apples to apples because you're doing state fiscal years and calendar years. But I can get to that information. That would be helpful. It was just odd to go along and hear a reference to the thing that I'm most interested in and think that you guys are going to develop a way to track the expenditures in relation to, but not to see that reflected in the actual documents. So I, if I'm missing a tracking that is ACO related, that would be good to know. It sounds like I'm not, but if you can send me those quotes that you had in the presentation, that would be great. Thank you. All right. Thank you, Susan. I see that more Wasserman has his hand up more. Hi. Thanks. This is such an impressive and presentation. I have a question that may be a little naive. Is there a way to look at expenditures with a little more granularity about the patients? So for instance, I'm interested in age groups. Medicaid includes two very different populations, a population of people, adults with disability, and a population of children. Is there a way to drill down into that? I don't have that information. We would have to drill down into maybe v-cures information to be able to get that for you. Great. Thank you. Thank you. Okay. Rick Dooley had his hand up. Thank you so much for that presentation. This is Rick Dooley representing Health First. And you had mentioned that there are challenges facing the independent practices that are driving independent doctors out and raising the hospital employed. Is there any way to compare, given the reduced costs of the outpatient independent practices compared to the hospital base, is there any way to compare what that difference would be in expenditure if folks remained independent as opposed to becoming hospital employed? It could if I was able to have that rich data sent to us. But that's been a challenge to get the independent physician revenue dollars. I'm using census information. Thanks. Is that into your question? I'd like to be able to get that information if we could have a resource, a direct resource. All right. No, that's good to know because we may be able to help with some of that data production. Thank you. That would be great. Other public comment? Other public comment? Hearing none. I just want to really thank Laurie and David for their hard work. Laurie, you've once again been a rock star preparing this analysis with your team and such short staff. You still were able to deliver it. And we truly appreciate it. Kevin, if I would like to acknowledge the people would be on slide 50. All of the agencies, commercial insurers, VARTA community. And as you mentioned, our teams at the ground care board for helping with this data report. Thank you, Laurie. So with that, is there any new business to come before the board? Is there any new business to come before the board? Again, hearing none. Is there a motion to adjourn? So moved. Second. Second. It's been moved and seconded to adjourn. All those in favor signify by saying aye. Aye. Aye. Any opposed? Thank you, everyone, and have a great rest of the day.


Hey, how's everybody doing today? This is your boy, Rich, and I'm here with a very special guest. We're here with Dylan How you doing today Dylan? I'm good. How are you? I'm doing very well We've been talking about a very interesting topic. Okay, so what was the first stock that you ever bought? So the first stock I ever bought was ACB myself, okay? So there's an article it says a cannabis producer just popped Apple as The favorite stock among Millennials and that stock happens to be Aurora cannabis What do you think? Why do you think that millennials love Aurora cannabis so much? Like do you actually think that Aurora cannabis has to potentially go up more than Apple? So I mean from my perspective and I think a lot of kids a lot of kids see the valuation in the cannabis market And they see it as a growing Exponentially thing. I mean a lot of kids do it a lot of a lot of people participate in it It's like a recreational activity And so like I think a lot of people see the market for it even as a recreational activity But like not like not even regarding the medical market for which is which is exponential And I think a lot of people Are viewing that as kind of like because like technology is like already a wave I mean like it's already been done I mean it's gonna keep growing, but I think like the next thing that boom up really is the cannabis industry And when you look at like the bigger picture, I mean the first thing you Google I mean Aurora cannabis is gonna be in an article like and there's a lot of speculation on it like both both sides But I think a lot of people with my like am I like everything? I think people that I think people are very They like like the volatility of it. They like to the fact that people are like not outright saying like oh, it's fantastic It's this I mean there's also bad, but they see like the growth in it They see that like oh, yeah, this is a somewhat risky investment But they see like the exponential growth that this company is able to able to keep up with because their company It's very acquisition heavy And I mean just as like a rate a regular follower someone that doesn't like understand or someone that is like very new to the situation I mean people are gonna see the fact like oh, they bought this people they bought this they bought that You know what I mean? They're gonna see that as wow I mean this is a company that's really like capitalizing on the global market and they could really like Exponentially increase something like Apple they're gonna turn something that's like an idea into like a multi-million dollar everything And they're gonna run the show. Very good. Now. Why Aurora though? Why not Africa? Why not? Can you be growth corp? Why were why do you think it's Aurora? Why is Aurora the number one? I Mean from the second I even laid my eyes on it I felt like I felt like that always had something like special to it because I feel like a lot of the other things It was more like positive and like Aurora I feel like people are kind of like trying to like shrug it away like it could be but it's not going to be and I remember I read a lot of articles that were like well, it could be you know Like it is what it is blah blah blah But I like really look through it and I was like and I think a lot of other people are gonna look at it this way Too and I think it's like just a fact of like they they're revenues increasing like crazy And they're just like positioning themselves just so globally there. I mean like like I said, they're so acquisition heavy I mean they have a big stake in a lot of things and so I think that they see that as Something that could just keep growing and growing and growing and like I think that they think that that and I think myself that it Can become an empire one day like something like Apple has I mean like absolutely a hundred percent now is Is it the price because obviously can't even grow to Zeta much higher price. Yeah, Africa is pretty close Is it the price that got your attention because Yes, so the price got my attention and I like that it was lower because I feel like with the lower stock It's like more opportunity for people to buy in more people more people realize the value in that and even like even that alone We'll bring it up. I mean, I think I think that at a low price like that that way It's even it's even better for people that don't have a ton of money to put in the market Because I mean when you have like a lower amount of money I mean you're you really tend to stay away from like the the higher share that the higher cost of shares I mean like you see like tell Ray and all that stuff I mean like they're up like 80 bucks like they're up there And I think a lot of people see like the affordability of it Which is I mean not an entirely wrong way to think about it But I think they feel like they can load up on more shares and they can get a bigger stake in it And I also think that going back to the fact that like there's a bunch of other ones like Africa is right there And I think that that's kind of like if you want to relate it back to the Apple analogy I would say that it's similar to how like there's Apple and there's Microsoft and everything I mean, I would say that there's very similar companies that are all gonna do very successful But and I think honestly, I mean you can have your fair share But I think that both of those companies are gonna do extremely well And it's it's literally gonna become like a Apple or Microsoft thing where it's like pick your poison I mean you're gonna do well either way What about the fact that the influencers are talking about it a lot? I was the first person I Remember on YouTube talking about our cannabis January 2017. It was under $2. And I remember making videos In 2017 when people didn't even know about our cannabis, then you fast forward to 2018 There was you know about a handful of influencers talking about our cannabis now you fast forward to 2019 and there's a lot of people talking about our cannabis Like me on YouTube Instagram Facebook different social media platforms Do you think that that has an effect on why millennials like our cannabis so much? So I yeah, I definitely do think that has a big play on it because I feel like they see the publicity of it They they see like if it's being I mean a lot of people Especially if you're not like heavily involved with the market reading a lot of articles If you're not like all the way caught up with everything If you see a stock that's constantly in the headlines constantly being talked about I think you could that you kind of see that and you're like Wow, like I mean that that and especially at that price, too Like it looks like wow that could be something that like turns into something awesome That could definitely be something that like it like it starts off low Like kind of like how Apple did starts off low and I'll look at it It's it's blossomed up to like a huge a huge thing where people like we're making like their retirements off it and I think that Definitely What do you think like I Been saying Aurora cannabis for two years. I think it's gonna go to $100 one day. What do you Potential for our Canada's one day. Do you see a $50 stock? Do you see $100 stock? What do you see? Yeah, I see $100 stock most definitely I think that once they get their their their share count cleaned up and they get all their ducks in a line I think that they're a very valuable company that will kind of I think that by doing that they'll be they'll eliminate a lot of their volatility and it'll become more of a Settled company and more established like kind of like an Apple and they'll be traded with like with that type of respect as well And I think right now we're seeing a lot of volatility because they don't they don't have that type of respect people aren't afraid to short them I mean they're just able to I mean people who know what they're doing are able to short them and abuse them in the market because They don't have everything that an established company would have just yet They have the potential just not just yet. And so I think that that that leaves room for that But I think that once that all gets out of the way. I think that we'll see an exponential growth. Definitely Okay guys, I want to let you guys know something Always do your own due diligence always do your own research before you invest in anything that we talk about here on rich tv live Okay, I am not a licensed advisor Dylan is not a licensed advisor. We're just Average people trying to do above average things. Okay, and we want to share the tools that we've learned how to use That can help us make money But there's no guarantee that any of these stocks are going to keep going up or they're going to go down We do not know nor do we control the market. Okay, but I'm going to tell you something. Okay Today I was listening to Bloomberg and an analyst got on there and he said Uh a question came on, you know, what do you think about cannabis stocks and the analyst said this He said cannabis stocks are overvalued Grossly overvalued. They actually asked him about aphria. He said I can't wrap my head around aphria I won't buy aphria because aphria is trading at a price to earning ratio that doesn't comprehend in my brain So this is a big financial fund. Okay, so I want to make sure everybody understands This is a game the cannabis stocks right now are trading at Values that are above the streets. Okay, so the street average is about six to 15 times price to earning ratio That's kind of standard for wall street and bay street across north america What's happening now with cannabis stocks? They've been trading as high as at some point when tilray was at 300 and canopy growth was at all time highs They were trading at 250 300 times price to earning ratios That is not sustainable. Okay in any world shape or form However, however Canopy growth has acquired billions of dollars Prono's group has acquired billions of dollars Aurora cannabis is in 22 countries and will be making billions of dollars in revenue This is why they're trading at these crazy Fundamentals which fundamentally right now can't be justified But in the future will be justified. This is why they're trading so high Which creates like you said massive volatility. Do you need very careful? That is why it's vital that we work together as a unit that we really Watch these stocks together. We support each other as a community and we find the bottoms We hunt the bottoms and we really work as a community to say, okay, we're at 52 week lows. Now's the time to buy Okay, we're at 52 week highs now's the time to sell and really learn how to make money During the patterns because there's patterns that are being created in this marketplace, which is literally a bubble We're living within a bubble And some of these stocks are going to go even higher and some of them are going to go lower because what's happening is They can't justify their price to earning ratios So that's why you're seeing companies like abadis that are having issues with the regulatory body here in canada Abadis with all the way down to six cents and now they're having issues with the regulatory body You're going to see examples of companies that will fail And then you're going to see some companies like tillray that shoot out the gate and they never come back down to earth Because they're in the right place at the right time and they've got a license to work in america And they're going to be a monster. So that's why they're trading so high And they have a very tight float and they don't have a lot of shares in the marketplace Which is crazy getting massive dilution, which is forcing the price up This is what you're going to see and this is why it's so vital that we have a community like we have here Where we can work together to identify the share structure Really learn about the management team learning about their revenues reading their balance sheets Learning to see which ones are really profitable. Which ones are generating, you know, a high price to earning ratio Which ones are trading at reasonable price to earning ratios learning how to read their balance sheet and see how much companies Debt ratio are and how much revenue they have in conjunction to their debt ratio These are all things that we have to get better at as a unit as a community And believe that we are getting better And we will continue to get better And if we continue to look for companies like Aurora cannabis And all the millennials are investing in buying Aurora cannabis and we can find the bottoms Like before I went on my trip. I bought it at seven dollars I just knew was the bottom because I've been watching the stock for two years, man So I kind of knew yeah, it's not the bottom, but it's gonna go up And I was gone for 30 days. I put in $3,500 bought 500 shares And I came back 30 days later sold yesterday at 10 77 pulled out $1,900 on a $3,500 investment Now all of a sudden I got $5,400 to play with and I'm gonna look for my next position in the next stock I can teach anyone how to do this. You can teach anyone how to do this Absolutely And we buy red and sell green we can win anybody can do this and obviously millennials are starting to do it They're buying more Aurora than they're buying apple It's crazy Yeah, I think it's awesome I think that I think that's awesome that we're seeing that especially with millennials I think that a lot of people are realizing the true value in the stock market and like just as a whole are Like kind of realizing that it's a great way to make some extra income and it's it's it's also like something to get involved with It's just something that to get up every morning and be like, it's gonna be a good day in the market So I think that that and that alone I think that that's an awesome thing that we're starting to see an increase in people investing and kind of keeping their eyes Open to the stock market and just getting involved. So I think that that's a great thing alone Well, you know what we've been talking for some time now So we're going to get back to doing more research because this is all about the research people. Okay, so Dylan Thank you for your time today I really appreciate your insight on why millennials and why young investors are interested in aurora cannabis I hope that you have more success with all of your trading moving forward. Let's do more videos Let's continue to talk. Let's educate the youth about the importance of investing Learning how to build equity in themselves learning how to invest in good long-term companies And learning that. Hey, you know what? We're in a wave right now in the cannabis sector and if you make some good decisions, you can make a lot of money Absolutely And with that money you can have freedom so that you too can go and travel to places like the dominican republic Or ever you want to go and travel with your friends and your loved ones Absolutely, I think that it's great. It'll definitely transform your life if you do it, right All right guys. Thank you for watching if you're not winning. You're not watching. This is your boy rich with dylan and we're out peace


Hello, everyone. My name is Michael Salah. I work for the French Network Information Security Agency. I'm going to talk about a project I started three years ago. So it's about hardening Linux and this talk will be a bit focused on containers. So to pick out the technology that takes place, well, usually start by compromising a process or set of processes and then gain more privileges, so elevate the attacker privileges to finally gain access to some sensitive data. So here we are going to try to harden user space to make the attacker work more difficult. So how to make something more harder? So of course you may want to use some good languages with some good security properties to avoid some common security issues, but you may use some legacy software or third party software, so you may not be able to follow these good practices. However, you may want to follow the list period principles, which means to only give the rights to the set of processes which only needs these rights to the common legitimate actions. And then you may use some compatibility techniques, like for example containers, or only using dedicated users for services. And here we're going to focus on containers. So for containers, there's some constraints and some pros and cons. What you want when you use a container is to add an abstraction from the host. So you may want to update your host in one time and update your container after that. So you don't want to sync all these updates. So what inside container image is maybe unique. So you need to have a security property tied to this container to the services running on it. And this security property should be independent from the host because the container is something standalone. Then what we want for this is to be able to embed the security policy in the container, in the container image to be independent from the host. So this multiple way is to enforce security policy on Linux. Of course, it's the four major LSM, which are a Linux app on board in Tomoyo and Spark. Other than maybe used to set some accesses on files or even tent work and processes, IPC. So it's designed to enforce and control in a fine way. However, they're not designed to embed their own security policy in your container. So you have to configure the security policy for the whole host. Obviously, there's some works going on with namespacing LSM, but that's not here yet. And last but not least, you cannot use, well, you cannot enforce security policy if you're not running as root. So you need to use the system administrator to be able to enforce security policy on your processes, even if it is an influential container. So there's multiple other features available with Linux. A really interesting one is a second and especially second BPF. So it is kind of a firewall to protect the kernel from user space. So I say the documentation, it is not a sandboxing mechanism, but it helps reduce the attack surface from user space to the kernel. And obviously there is namespaces, which are the basis for containers. So this is not an access control system, but it may be used to only show some parts of the system resources, like only some file hierarchies or some subset of the network. But you cannot fully use all these features in an unproledged way. Even if these are user namespaces, you cannot use every namespaces feature with it. And there may be some concern about some security issues. And another interesting point with SecComp is that you can embed your security policy, even if it's not a sandboxing mechanism, in your applications and in your container as well. So for example, there are some container managers which use a second BPF to add in their containers at one time. So it is independent from the host. Obviously the host needs to provide some features, but not the security policy. And then here comes Linux. So Linux is a Linux security module. So it is targeted in fine-grained access control. So you maybe, you should be able to enforce security policy on FirePass and some more complex objects that you cannot do, for example, with SecComp. It is designed to be available for every user of your system, root user or even invalid users. And it is designed to be able to embed your security policy in your application, in your container, without being too tight to the host. So it is a way to create a programmatic access control. So now let's take a look at what Linux may look like at host. So this diagram gives you an intuition of how it works. So in this example, the process sunbugs itself. So it created a set of Linux programs which are loaded in the container. And these programs are coded to design to filter some access to the system. In this case, these programs filter the open system. So every access to files with open or access or whatever. So this investment is only done for the process which enforce security policy on itself, not other processes. So if this process is part of the container, this security policy only implies this process. So it is independent from the host. So there was some version of Linux. And the last one will be the eighth version. So it is not ready yet, but it will be released in the following weeks. But I will give you another view of what's inside this patch set. And anyway, I published an alpha release of this version. So you'll be able to check it and test it if you want. So this patch set for the Linux kernel is a minimum variable product. So it only means to demonstrate that it may be useful for a lot of use cases. But without bringing too much code to limit the work of the kernel reviewers. It is focused on file system access control, which is one of the most difficult kernel resources to enforce an access control on. And underneath it is powered by eBPF. So what is eBPF? eBPF stands for extended declare packet filter. So it came from the classic eBPF that you may know if you use TBDM, Wildshark, to filter network packets. So eBPF is an in-kanal vector machine, which is designed to safely execute code in the kernel. And this code is loaded by the space. And may be loaded by entry-age processes as well. It is already wireless in the kernel. So for example, for the network filtering, second eBPF uses it internally, and tracing, debugging, and a lot of other stuff. So there's two main important features provided by eBPF, which are really important and useful for Linux. The first one is the ability to call arbitrary, well, not arbitrary, but dedicated functions, which are designed to be run for static type of eBPF program. There's multiple type of eBPF program. So there may be one for filtering networks, one for debugging, and so on. So there's also one for Linux. And the other really important features is a new kind of IPC, which is called eBPF map. It is a way to store data, which may be available from user space, and from any eBPF program. So this kind of table, and there's a set of keys, which are tied to a set of values. And of course, because this is, well, eBPF is meant to load code and run code at the kernel level. There's some security implications. So there's some security safety too. The main one is a static program verification at load time. So whenever user space loads a program in the kernel, the kernel checks a lot of things that eBPF program may do, like, for example, accessing memory, and while the kernel follows what the eBPF program wants to do with this memory, so it taints the memory and do a lot of checks with that, which allow, for example, to restrict pointer leaks from the kernel. And obviously there's an execution flow restrictions to only execute code from the eBPF program and not jump in a number of address in the kernel. So that's what is used in Unlock to express an access control rule. And what is used to enforce an access control rule is the LSM framework. LSM stands for our Linux executive models. So it is mainly an API to extend the kernel with code to enforce security policy on user space. There's a lot of pretty decision and enforcement points which are scattered all over the kernel just before the code that may use some kernel objects. So, for example, if you're trying to open a file just before the open actions, there's a check to check if the current process is allowed to go through this path. And, well, there's more than 200 hooks in the kernel, so it's quite complex. And all of them are quite specific to the kernel code and they may evolve with the kernel code as well. So it's not a stable API and it's done on purpose. With Unlock, the idea is to try to bring some part of the LSM features to user space in a safe way and accessible to input processes. So it's a bit different. For example, the idea of hook in Unlock is to define a set of actions on specific kernel objects like, for example, open a pass and walk through a fiber or even open a network connection. So the programs are EBVF programs. Lennoc programs are EBVF programs typed for Lennoc. They're designed to check some access related to a specific Lennoc hook. And triggers are meant to restrict the way, well, to only run this program when they are designed to be run. For example, to only check read, write, or use the elections and so on. So now let's take a look at how we can write a Lennoc route. So a set of Lennoc programs. So it's mainly EBVF. The main way is to write the EBVF program in C. So actually it's not really in C. It's a subset of C, but it compiles with Claim, which is really useful. So you write your EBVF program in C. You then compile it and you get an EBVF bytecode. Then you can embed this bytecode in your application. And when this application is run, it's executed. So this can then be able to load the EBVF program in the channel. So let's take an example. So the example I will follow for the next slide is with two goals. So it is really a common use case to be able to access files in a read-only way or in a read-and-write way. But it's a bit more than only pass. It goes through five descriptors. So then we want this security policy to be enforced on set of processes. And this security policy may be updated at runtime. So you can go check the code. I just uploaded it on this website. But I will explain right now some part of it. So to be able to enforce security on a wireless of file hierarchies, you first need to create some wireless. And actually in the kernel, there's no way to express this for what is needed for London. So the goal is to be able to list a set of files. But there's some challenges here. First, obviously we want this to be efficient because there's a lot of access request at the same time performed by a lot of processes. We want this wireless to be updatable but by user space at runtime to be able to add more files, more restrictions, or to remove them if you want to. And last but not least, we want this wireless to be updatable and to be useful for infillage processes as well. So for example, we cannot choose extended attributes from a file system because extended attributes are dedicated to, well, can only be written by someone that is allowed to write on these files. So if you are in a real new environment, you will not be able to write extended attributes. So that's the problem. And another constraint is that if you want to run multiple security policies in conferences, you want to compose them so you need to be able to identify a file, or find a keys, for multiple security policies which may not be run by the same user. So you need to be able to stack, well, to have multiple identifiers for the same files. So the idea is to create a new dedicated ebf map. So this is already a multiple ebf map for multiple use cases. And this one takes as a key an inode, which is not only the inode number but the device as well. So it's an inode from the corner. So it is used as a file descriptor. And the value is a 64-bit value which may be used as a tag. So it is kind of independent extended attribute, independent from the file system. So with this kind of file system, we are able to identify a file, not a file IACS, but which is quite useful is to say, okay, this directory I want it to be available in a read-only way, but you don't want to list every file in it. So to express a file IACS, there is an Azure feature from Landlock, another properties. Landlock use ebf programs, but it can change them in a session. So there's multiple Landlock program type as well. The first one here is called FSWalk. It is called for every walk through a file path. So every directory you go through, this program will be executed on it. And in this example, I changed an FSPIC program with the FSWalk one. So the FSPIC program is dedicated to evaluate what you allow the access or not to the leaf of a file path. So usually a file. And you can then add some triggers to only trigger this program for a subset of actions. In this example, the open changing directory and getting attributes. So I created a subset of triggers which are related to read-only actions. And for write actions, I created another FSPIC program, which is also triggered for when accessing a file, so the leaf of a file path. And this one will be triggered for write kind of operations, like writing a file, writing to it, or linking and linking and so on. So how does this work? This set of programs are able to share a common value, which may be used to identify a state across execution of multiple programs. So let's see an example. Is this example? So let's say we are in a container running as a web server. And the web server wants to access a file, which is slashpublic slash web slash index.html. So the first execution of the FSWalk program will be to allow or deny the access to the first element of this path, which is the slash, the root of the file system. And at the bottom you can see the map, which was previously loaded, and set with three keys, slashetc, slashpublic, and slashtmp. Each of these keys is tied to a unique value, which only makes sense for the program you only wrote. With this case, I decided that the value was only one for read access and two for read and write access. So this FSWalk program, when executed, looks for the i-load, the file, in this map. So there is no slash in it, so it just allows the path to go through, and then there's another one, which is executed. So this FSWalk program is executed and can then look at which i-load is requested. So the public i-load is in the map, so the program knows that it is allowed to be used as a read-only action. And then this program can then write it's in its context cookie that, okay, I saw this, I saw a file, which is a load, a directory which is a load. So for the next one, let's remember that we are in an, well, an identify file archies. The next execution, see the web directory. The web directory is not in the map, but that's a problem because we know that we are only in a file archie, specific file archie. And at the end, when we reach the leaf of the path, the index.html is not in the map. However, we still know that we are still in the file archies, which is tied to the slash public. And then the specific program, which is tied to the open action, can allow this action to be performed. So let's take a look at how we can write this kind of BPR programs, learning programs. First, we need to define some metadata, some properties. So as, like I said, we need to tie a learning program to a learning hook. In this case, it is an FS hook. Then we need to chain it. In this case, it is a third FS pick, well, the third program, which is a FS pick, and then it is tied to a previous one. From the user space point of view, you identify a learning program with a file descriptor. And then you can attach some triggers to this learning program. In this case, the append triggers, trace actions, and so on. So all of these are dedicated to write actions because I wanted to express this kind of actions. Then we need to write the actual BPF code. So it is here a subset, well, a snippet of the actual code. You can see it in the website. But it's interesting anyway. So the BPF program here is kind of a main function. And it takes as an argument a context. In this context, there is mainly two values. The first one is a cookie. So you can use this value to keep a state between different program execution. And the second one is the inode, which is inode you can then look if it is in a map or not. So here the first inflation is just to copy the cookie. The second one is to call in function. So this function basically looks at the map. And if the inode, which is in its argument, is in the map, then it returns the tag, the value of the inode in the map. Otherwise, it just keeps the tag recorded by the cookie. And if the cookie contains a tag, well, which is allowed to write something, so it is here an average value. I think it's something like two. Then the program allows the action. Otherwise, the action is denied. So once you return your log program and the log metadata, you need to load this in the kernel. For this, we use the BPF Cisco. This is a pro-load command and some attributes containing mainly the BPF bytecode, the BPF type, which is here, learn a cook, and then the metadata, which are type specific to learn a look. That we saw just before. So the process called BPF program and load it, load the program in the kernel. Then to apply this program to the current process, we use a second Cisco. But we do not enforce second filter. We enforce a learn a program. So here there is a new second Cisco command, which is to prepare a learn a program. And as arguments, we put the learn a program. So it is a chain of program. So we loaded the BPF program in the kernel and then we can apply it to ourselves so the process applies its own program to itself. So this process may be a container manager, for example, like the currency and so on. And then for every action that this process performs, we press on the kernel, the workflow goes through the Cisco entry point then reach the LSE book, which can then call the learn a look books, which are then tied to a set of learn a look programs, which are designed to be triggers for such an action. And then this program can allow or deny the requests and forward it to the dedicated code. So this first one is done for the current process, but not only this one. So let's see another example. Here we have a first process, P1, which is about to fork and create a new one, P2. But if this P1 process wants to enforce the security policy on itself, it can. And the new children from this process will then inherit this security policy as well. So it's exactly the same way as, say, COMP works with filters. And if the P3 process wants to enforce its own security policy on itself, it can too. So for example, if you're running a secure server in a container, your container as P1 can enforce security policy for all the container, and the P3, so the web server, can also enforce its own security policy on itself. Or even if you want to run a container inside a container, well, you could. You can enforce nested security policy. And obviously, the P4 process inherits from the P3 security policy and the P1 as well. Now, let's see a demo. So it's really a simple one. There's two kinds of wireless which are configured by user space. The first one is a really set of five arcs which will be available in a really way. So for a web server there's slashpublic and slashtc, slashpc, and so on. And another wireless which is available, well, allowed to be written on. So the slash TMP to be able to write some temporary files. But also for the example, I added the STD IO. So STD out, which is identifying with PROXSELF FD1. So the first file is filters. So let's see that. So let's say we are running as a web server user. So we are in the public directory. We can list the file there. So there is some junk here. That's not one. We can write some files. So here, for example, I write the file index.html. So that's common use case. So let's say it was the root user who configured the web server. And then we want to launch, let's say, a web server. In this case, it's a shell, but that's different. So there's two variables. The first one is an environment variable to list the path which should be available in a really way. So you can see this slashetc, and the stuff slashusr and slashpublic. And another variable is called llpasswithwrites for withwritepass, which includes the STD IO, TMP, and so on. So this London Web Program is a sample that you can find in the code. And it will scan your first sandboxer or a really light container manager. And so it will run the binbash, the shell. So here we are in the new environment. So it is the same space, but only with London World Supply. So we are in the same directory. You can still list the files inside. But as you can see, there's some access which are denied. So you can see that the dot dot is denied. So dot dot points to the slash directory. And indeed, the slash directory was not allowed to be accessed in a really or no right way. So we cannot get some info from this directory. However, we can get some info from the rest. And of course, if I want to write some files in the directory, it is not in a really way. So it is only accessible in a really way. And if we go in the TMP directory, we can list what's inside. And you can still create files, as says the security policy. And so as well, we can see the root. But if there is some private directory, we will not be able to see it as well. And so just to finish, as well, we cannot go to the root.  So to wrap up, London Lock is dedicated to other user space. So in a programmatic and embeddable way, so you can program your own access control rules, as you wish, and embed them in your applications for set of processes, which is independent from the host. And one thing I need to demo here is the ability to update the wireless at runtime. So that's maybe really handy. And it is designed for infrared use. So you may run it for any user. So currently some patches, well, I made some little patches in the kernel to just prepare the landing of Landlock. So it's about 2,000 single line of codes. Most of them are in the security Landlock directory. In the links source code. And while you can follow the next, so the V8 patches in the links kernel list on Twitter, and I will release the next one in the following weeks. So we can get some more information and we'll get some more in this website. Thank you. Any questions? So can this only be used to filter authorization to the file system? Or can you also change the API code? What I remind is to be able in a container to have some user ID and to actually access the file system with another user ID, which means that if you actually do some change to the API code, not just utilize... Could I do this? Yeah. Landlock is dedicated to enforce the ability. So it is a new layer of security above the existing one. So if there is an existing security policy or even the back security policy, you cannot change it and you cannot map one way to another. So for this, you may want to use user namespaces. It's going to be a bit difficult to figure out like any other question. Like half the room is changing already. Yeah. It looks like not. Well, thank you very much.