And this is the House Healthcare Committee. It's Thursday, February 10th, it's about 1041. And we are continuing with the opportunity to field questions from committee members with representatives from the Green Mountain Care Board who we heard earlier in the morning in a separate Zoom presentation that is available and is available on our committee webpage around hospital sustainability. It seemed to me that if we were able to do this that there might be an opportunity for our committee to ask more questions and to get more information about the issues of hospital sustainability and some of the underlying issues which we honestly have taken less testimony on than our counterparts in the Senate to this point, they will bring a bill to us after crossover that we'll build on some of this. But today, I appreciate your flexibility. I'm gonna suggest that, I mean, I don't know how what questions we'll have or how long it's to go but I'm gonna suggest that we go, we think about going at the outside to 1130 and maybe, and we'll see how we're going in the meantime. But appreciate your flexibility. So I'm gonna turn to Representative Houghton and I don't know if that's on behalf of someone in the room or yourself, but go ahead. Actually, for myself this time, and then Representative Houghton, you have a question. Okay. For those, for the Green Mountain Care Board, I tend to raise the hand for those of us in the room since you can't always see everyone. So my question is this and I was talking to help all of us were talking in the hallway about the presentation, which was wonderful. And personally, I find this next stage really exciting. And so I'm really, I give you all a lot of credit and I appreciate the thoughtfulness you've put into this and really press our homes comments on how hard change is and understanding that we will be sure to keep that in our minds as we work with stakeholders throughout this whole process. One of the most exciting pieces for me would be the community aspect of this. And I'm just curious what the conversations have been or will be around when you say community outreach, how does that work? What parties are included? How, you know, not just specific healthcare providers but are there other types of stakeholders that you see at the table? Well, I'll start and just jump in if I get sidetracked here, but the full process hasn't been defined yet, but all parties need to be at the table. So there has to be at the same time that there's conversations with the medical community in a given health service area. There has to be conversations with the community itself. It has to be a patient centered approach, the conversation and one where everybody feels like it's best for them. So it can't just be closed door meetings in the CEO's office at the local hospital. That won't work. Jess, you wanna jump in? Yeah, and I was just gonna say, I mean, I think we have to start with hospitals and their trustees who are representative of their community to be sure and walk through some of the data that we've observed on prices and on costs and on volumes and really help some of them help us understand what we're seeing and help us think about what we're seeing and observing around some of the high cost areas. We have to then expand it, these conversations to the entire care continuum, providers in the community, independent providers in the community, folks that are providing mental health services. I mean, if we really wanna think about how we can deliver essential services and care better to our communities, everybody has to be at the table. As Kevin said, local businesses who are paying for effectively the premiums that are associated with those commercial prices, they have to be at the table too. I mean, I think we have to really start to dig into the data, get everybody involved in understanding what we've observed, what we've seen. Some of that, there was a table in there. Let me see if I can figure out what slide it was. I don't have it in front of me. I do, but I'm trying to flip through. It's slide 16 and side 17, you know, some of those slides really reveal some interesting data around the costs of some of our smallest hospitals, high fixed costs, low volumes in those areas. And so they're translating into higher prices that are being faced by the patients in those communities. And so maybe compromising access. So we have to have those kinds of conversations. We have to share that data and we have to understand where are their gaps in care. So there are communities that don't have enough primary care. There are communities that don't have access to mental health services. What can we be doing to ensure that access? So those are the types of conversations that we have to have at the community level with everybody involved and everybody at the table. And can I just add quickly? Go ahead, Lori. Did you want to say one more thing, Representative Houghton? I thought I was echoing, but no, go ahead. I'll follow up after you. I will be very brief, but I thought of this as we were presenting earlier. We are looking at equity as well. And I think it does, your question, I think is we need to look at the entire community and where are those gaps in care? And there's all of the equity. I don't want to start ticking them off, but in particular as it relates to rurality, and that is a focus of our federal partners as well, equity of all sorts, but in particular, of rurality. Thank you. And if I can just make a follow-up. I liked when someone mentioned social determinants of health, and what I'd like to suggest, and I'm sure you're already thinking about this, is it's not just the healthcare provider. So can we have the family centers involved in the conversations? Can we have representatives of the schools involved in the conversations? There's a lot of healthcare that happens within our schools, and there's a lot of money for mental health flowing through our schools. And we seem to not bring them into the conversations. How about food shelves? If we're going to reimagine the system, which is kind of what we're doing here, it needs to not just be healthcare providers, but also the other providers in the community that make up the whole person. So that would just be my comment. And if I can just add one more. Sorry, then I'll stop. Just to make sure that we're not relying on the healthcare providers to provide contacts in the community for other people who should be at the table, but that we're going to other leaders in the community to say, these are the conversations we're going to be having, who should be at the table, and how do we best draw in the community to watch these conversations and provide feedback in other ways, such as surveys, or, you know, feedbacks that we mount in care board, you are all extremely transparent, but I think a lot of the Vermonters don't understand how to gain access to you and how to follow what you do and be involved in that transparency. So I just would hope you'd keep all that in mind. Thank you. I just want to say, I think that's brilliant. And I think it's important that we have, you know, folks who are delivering social services be a part of the table. I love the idea of bringing schools in. And I think what we need to do a part of the ask is to identify facilitators who can help us think through how these conversations can be done effectively, building consensus and thinking about who needs to be at the table and what information do they need to make thoughtful decisions. So that's part of where we need some expertise here. Right. So I have two questions. First of all, it was sort of touched on on that timeline slide, but I need some help understanding the connection between first of all, our all payer model, which is premised on on needing an ACO because that's the brings in the Medicare, which in Vermont right now is one ACO, the one care. So how does one care through that series of connections play into what you're presenting here? So one care, I think will always have a role, mainly because they have such close ties to the UVM network. And so I think that care coordination and data analytics they'll continue to provide that and it'll be a necessary piece of what would be done. And they could have a role outside of the network as well, as long as they're delivering the type of package to each local health service area that is providing them with the right analytics, the information and the care coordination. So as it fits into the model, the model doesn't call out one care Vermont. The model that we're currently under talks about having a flow through accountable care organizations. The federal government had always envisioned that there would be multiple accountable care organizations. And if you remember the history in Vermont, at one point there were three different groups that were trying to set up an accountable care organization. There was one that was being worked on by the FQHCs, one which became one care and the other was the VCO, and I think the VCO envisioned that they would be the one that would bring everybody together and merged into one. But the one that succeeded in being able to set themselves up was one care Vermont because they had the resources of Dartmouth and UVM behind them. And the federal government usually asks in meetings, do you think that it's okay to only have one and it's kind of a mixed answer because what I say is it would cost a lot of money to set up a second administration and set up IT infrastructure to have a competing ACO. Not that I'm opposed to that because I actually like competition and I think competition keeps everybody honest, but I'm not sure that it's bad that we don't have competing ACOs right now. My gut still would be happier if there was competition in that market, but we don't. So that's how the money flows under the current all-payer model agreement. Why we need the federal government's participation to really make global payments work is Medicare, even though it's not the largest percentage of the population, it's the largest consumer of healthcare. And when you talk to hospitals, that's where the majority of the dollars are flowing. So what we're hoping and there's been really good success with a model in Pennsylvania that involves global budgets and that built upon success of a model that had been in place in Maryland. So we're not going to unknown territory here and in fact, our counterparts in Washington are very excited about what's happening in Pennsylvania. And I think that they would be very welcoming to a model that moved further in that direction. And so I would hate to see us go on our own so that that big piece of the pie Medicare wasn't part of the global payment because I think it's essential for the success of that. And maybe I'll just add out a little bit here. I think that the next federal agreement, the hope is that it really moves us much farther away from fee for service, which we've shown as we know is problematic towards more of this value-based payment, ideally global payments. And as Kevin said, we need to make sure that the next federal agreement has Medicare at the table in those global payment models. So without, you know, we don't want to speak for the other all payer models signatories or the next federal agreement signatories, but I think the board would want to incorporate a lot of the learnings that we've seen here in our sustainability analysis into the proposal for the next model. And the hope is that the work we're talking to you about today is going to help communities get ready for the changes that are coming their way, contribute to the planning efforts so that they can be incorporated in the next all payer model proposal or the next federal agreement do at the end of this year. And I just would say, you know, I appreciate Kevin's comments. This work can happen with or without an ACO. It's agnostic to an ACO. It's about changing the payment system and it's about ensuring that the system itself is efficient and is maximizing quality access and minimizing costs. That's the goal here. I also wanted to make clear that we're just one signer on the agreement in that we're not driving the negotiations with the federal government that the agency of human services is. And I don't want them to think that we're out in front and trying to dominate this conversation. What we're trying to find out is if this is a viable path for the future of healthcare reform in Vermont. And so we're working with them. And I worry that sometimes people might think that we've taken control of the conductorship of the train and that we're doing this on our own. And I don't want that message to be out there. Yeah, I guess I have to articulate my question better because I got sort of lost in, I'm just trying to, the concept of the global budget. I guess the question is, does that go through, does that go through an accountable care organization if it's keeping Medicare at the table? Because Medicare depends on that. Or where does the money, does the money flow change? Does it not go through accountable care organizations or does that lose Medicare? So there's a number of different possibilities that it where, how it could flow. So it could flow through state government. These are all things that would have to be negotiated with the federal government and what they would feel comfortable with. Where they have had success with global payments. What is in their minds has made it work. So for example, in Pennsylvania is that they set up a regulatory system similar to what we have in Vermont. So if you're doing a global payment model, rather than going through the different line items on a hospital's budget, what the regulatory work that would be done, hopefully by us at the Green Mountain Care Board would be reconciling that bigger global payment and making sure that the quality of care and the access to care is there in every area of the state. Because then the shift is more away from are you doing everything right to keep your hospital financially afloat?  And so those are details that have not been worked through and that's part of what this process would involve. So my second question is, because of course, I think all of us worry about, there just seems to be a lot of duplicate care management and duplicate analytics. So when you reference, well, there's a role for that analytics, but analytics is taking place different places. When we start talking about this overall, where are our resources and where are our gaps on all of the different fronts in terms of care, potential centers of excellence, workforce issues? It seems like we already have the structure to identify, we already have the tool there, but we haven't been using it in terms of the health resource allocation plan. That's its intended function. So I'm a little unclear about what new things we're thinking of creating versus existing tools, whether it's analytics going on in care's role versus Green Mountain Care Board. Just seems like there's a lot of pieces out there. Looks like Susan would like to weigh in. Just as a representative Donahue, you are asking the questions and I know Representative Chair Lippert is going to have Donna Kinzer or have her present to you. I don't wanna assume that you did mention that earlier. These are the exact questions that she asked that she did for the Health Reform Oversight Committee this summer. And I believe that that would provide a starting point to some of those questions that you have because I think if we were to answer all into those granular details at this point, I think you'll see from her presentation that's exactly what she was setting up. Big picture, she was looking at global payments as a solution to a lot of the things we're seeing in Vermont and getting more folks moved over to value-based care. But she did address the data gaps as well. And I'm happy to share that with, share her presentation with Claire if that would be helpful. Sure, that'd be great. I will hold my question for when we get there. Okay, that's great, that's great. Okay, so let's move on. Representative Black, Representative Houghton, I think did, did I see Representative Peterson in his hand up at one point? Yes, yes, a long time ago. So my hand is for Representative Peterson and Representative Page. Okay, and I want to weigh in with some questions myself as well. So let's go first to Representative Black, then Representative Peterson, then Representative Page, and then me. Thank you. So I have a comment. I also have a question about something that I had heard 20 minutes ago, 30 minutes ago, whenever it was. Much to Representative Donahue and Representative Houghton's point, I do hope that as we're looking at moving towards sort of global budgets that we're taking into account services that are being provided currently that may not be in the most efficient manner that they could be within the system that they are now and that we're not just turning into a global budget and asking you to be all things to everyone for every service. I'm thinking about independent ambulatory care centers, primary care. And we know that community-based services are oftentimes much less expensive to provide with communities and also oftentimes better quality. So I hope we'll be looking at that sort of thing. That was my one comment. The other thing was, and I think Professor Holmes, you had mentioned this regarding the analytics and the data, you had said, we need to find out what data should we be collecting? What quality measures should we be collecting? And I'm thinking about the fact that we've been on the all payer model now for almost five years. What have we learned about the data that we've been collecting for quality value-based payments in that model that we could be moving forward and where are our gaps and what are we missing? That we haven't learned yet, I guess is my question. Go ahead, Elena and then I'll add, sure. I was just gonna say, I think it's important to remember that the all payer model measures are not hospital specific measures. So that's the first thing. And they're much more focused to kind of some goals under the agreement. I think the work that we're currently performing with VPQHC and the hospitals will allow us to have an understanding of all of the different quality metrics that hospitals are or are not participating in reporting. So there are a lot of programs that require them to report uncertain criteria, but it's not uniform across hospitals. So once we have that, I think we'll have a better understanding of where the gaps are, but that deliverable won't be prepared until later this summer as well. And I guess I would just add to that with some of the things that we're trying to explore with understanding hospital quality specifically is that there are data that are collected at the hospital level, but for many small hospitals, there are such low numbers that the data isn't collected. And so we're trying to identify what are quality metrics that could be specifically used for small, rural hospitals that have low volumes. Okay. Let's turn to Representative Peterson and Representative Page. Thank you, Chair. My question, let's see, I'm trying to do three things here and kind of lost track. I've heard for a year and a month about switching from pay for service, fee for service, to fee for value, fee for health. And I guess I'm still not understanding what that really means in terms of its impact on if there's any at all on the service given the patients. I keep hearing about it and it's one of the recommendations that we do it. It was a recommendation last year and I'm struggling with what it means, first of all. And then I saw a slide here and we've been talking about low volume in some hospitals. And I'm wondering if that means that we are gonna determine the value of the hospital to be a certain amount because of where it is, shower money on it and not worry about the low volume. And I'm wondering if that's what it is or if it's something different than that. So I'll start with your first question, Representative Peterson. What is the move from volume to value? And what that move is, is that there's a lot of empirical data and you may even want to invite in Elliot Fisher from Dartmouth. He and others at Dartmouth did an analysis that a quick sum would be that just because you have more care doesn't result in better outcomes. So you need to have the right care and what you have now is a perversion of the care that's delivered in the system. So for example, if a hospital's big ticket items are on ortho procedures, another procedure might be put by the wayside. And most recently, I heard the story of Ramonter who had a positive test from a cologuard that indicated that there could possibly be cancer. And... Colon cancer. Colon cancer, yeah. And the problem was that there wasn't available procedure room space because the ortho surgeons were given priority for that space and it already booked it. So it just... If you're giving a hospital lump sum of money, what you're expecting them to do is to give people the right care at the right time. You don't defer somebody that could have cancer. You don't have them wait. In fact, that's one of the problems that we have right now in patients presenting themselves at hospitals for the last few months is because all non-emergent care was shut down during the early stages of the pandemic. People weren't getting the screenings that they should have gotten, the demographies, the colonoscopies. And so when they show up, what they have is something that has progressed to a further point on the continuum and they need a higher level of care. So patients that are going in the hospital right now are more acute than they were pre-pandemic. And that's exactly the wrong thing. So what you wanna do is be able to have each local community set up a system where... So for example, you can pick high blood pressure or diabetes or any one of the number of chronic illnesses and Representative Peterson, the chronic illnesses, even though it's 20% of the population, it's 80% of what we're spending on healthcare. And so if you can prevent somebody and help them eat better, get better physical activity when they're diagnosed with pre-diabetes and get them on really a regimen that will keep them healthy, then they don't need to go in for an amputation or lose eyesight and things like that. So what you're trying to do and what the whole first movement was way from volume because volume is about keeping the cash register ringing at the hospital. And too often, even though I don't think a lot of it is conscious in that somebody is thinking, we just need to bring in the dollars off of this. But what they're thinking is we've got to keep our doors open so that we provide all care to the community. So we need to have the higher pay for the surgeons who are bringing in the dollars to the hospital. And so that's the perversions in a fee-for-service world. And we wanna move to a world where people are treated holistically and that's really the move. And I probably haven't really answered that first part of your question, have I, Art? No, you have answered a lot of it, Kevin. In my experience, just one guy's experience, it seems like the physicians I've seen have always talked about weight, talked about what you can eat, talked about these things.  Don't get me wrong, they're very important, but I struggle with what we're trying to get at. Frankly, I don't know if it's doable. I really don't, I mean, but do you value your health? The individual has to value his health. And I don't know that a hospital, but my overarching question at this point, you know that, and it's an easy one, not an easy one, but it's fundamental. What role do we play as legislators in this, okay? In other words, if that's the way you wanna do things, why don't you do it? I guess it started to be blunt, but I'm just, what's stopping you from doing this now? So just as you passed Act 113, which set up the framework for regulating the all-payer model agreement, this isn't a lone ranger effort by the Green Mountain Care Board. This has to be an all-in effort from government as well that, so in other words, you would have to be supportive of a global payment model through Medicaid. Diva's a huge program. And so without the legislature support and commitment to it, it would be almost pointless for us to try to do it on our own. And I don't think we could do it on our own. So these payments would come in a different form but then they come now. Is that what you're saying, or different values in different places? Yeah, rather than sending out a bill for each single procedure that occurs, it gets rid of a lot of that administrative nightmare following the dollars. And Elaine, I see you popped up, so why don't you jump in? Yeah, no, I think you can think about it in terms of an allowance. The hospital doesn't have to earn its dollars by seeing patients, but you give them a lump sum and say, here's your lump sum, you have to provide care for this population. It gives hospitals more flexibility to treat patients in different ways than they are currently right now. So you can hire a health coach. Some people that might not work for it. Other people might find it useful to check in with a health coach as they make these transitions. You can hire mental health providers right in your hospital. There's some things that are not currently reimbursed under the fee-for-service system that still provide value to patients and help them make healthier choices or help them identify health needs sooner. Those are the kinds of investments that hospitals can make when they have this global budget and they can plan to provide care for a population rather than just waiting to see who comes in the door. And so I think those are the kinds of dynamics we're trying to change, but we're not in the business, we're not advocating for managing what providers are doing that is not what this is. I think what we're doing is saying, hey, providers can't provide the best care to patients when they have to think about how they're gonna keep the lights on. How do we flip those incentives so providers don't have to worry about that and they can focus on what they wanna focus on, which is keeping people healthy. I think I can just add to that a little bit. I think right now the service lines that hospitals are optimized for fee-for-service revenue.  Sorry. So the service lines are maximizing fee-for-service revenue. So they're investing in those services that have the highest margins. And that makes a lot of sense. The hospitals are not to blame here. They are reacting exactly to the incentives that the fee-for-service model has created. But that means that they're gonna be reliant, for example, on orthopedic surgeries, even if they can't meet the minimum volume thresholds that we know are out there for quality, they're gonna wanna rely on that because orthopedics has a high margin.  So they're doing what they need to do to keep the lights on in the payment world that they live in. So their orthopedic surgeries where they have high margin are actually reimbursing or making sure that they have enough reimbursements to keep the birthing centers open that are low margin, because that's how the fee-for-service system works. If we move to a global payment model, as Elena said, and there's a fixed payment that's given to hospitals, what you're gonna see and what we hope and what's starting to see in states like Pennsylvania and other places is that there's a reallocation of resources towards the highest value care because now the hospitals have a sustainable flow of dollars coming in and they can reallocate. And you're gonna see more investment in primary care, mental health, care coordination, social services, things like that, because that's where the highest return on investment is. And they don't have to rely on just high margin volumes to keep the lights on. Okay, the global payment system work. Could you repeat? Or a combination thereof? Yeah, and what did you have? Just trying to understand. Can you repeat the first part of your question, Arc, is we couldn't hear it. The global payments that are given to the hospitals, they come from a fed money, state money, or a combination of both. How does that dynamic work? And then what do we do to measure the success of this? So it would be a combination of both federal and state because the federal government runs the Medicare program. And again, that's the biggest chunk of dollars that are going to flow through the hospitals. State runs the Medicaid program. That's another huge chunk. And ideally you would be able to tie in commercial payers, but these are all things that would have to be worked out and figured out, but there could be a flow of funds that put the monies together before they were distributed or there could be a flow of funds that just went directly from the individual payers to the hospitals. And do you think this will cost less, Kevin? You think it will be more efficient doing it this way than feed the service? I guess that's why we're doing it, or one of the reasons, not the primary, but one of them. Yeah, I do think it would be more efficient. I think that it takes some of the efficiencies, the inefficiencies out of the current system. And so otherwise we wouldn't be doing this if we didn't think that we could get better outcomes. Thank you. Okay, so I'm going to turn to Representative Page. And it looks like we might have questions that go beyond 1130. We'll see how we do. Representative Page. Yeah, Representative Curtis. Just a couple of questions. This global payment system, it's going to be able to, the hospitals are going to be able to reallocate some of their services, I guess funds to other services. Will hospitals lose current services that are available and those services will they go elsewhere as a result of this? That's a concern of mine. And then the other issue is, okay, we implement this. And we find out it doesn't work. Do we have a backup plan? Are there backup plans to make corrections as Chair Lippert mentioned earlier, flexibility? That's the key, I think to everything. Is the Green Mountain Care Board flexible to make necessary changes as time goes on to fix this? I think without flexibility, it would be doomed for failure. So you would need to have flexibility because you're going to see that populations will move and there's going to be other changes in demographics that occur. So flexibility is important. As to the first question, say for example, where you are Representative Page, you're not close to anybody else. So it would be pretty hard for your hospital to shed services and still make sure that people in that area of Vermont are getting proper care. There could be shared services in hospitals that are closer together. And that would make a lot of sense. So for example, one of the strategies that came out of the Springfield bankruptcy is a hope that there could be an alliance with Dartmouth. And because of what took place in New Hampshire, Dartmouth is in the process of acquiring the Catholic hospitals out of Manchester and Southern New Hampshire, which is where all the population is the granite hospitals. And that's still, I believe, under the Attorney General's office there that makes decisions on whether or not a hospital can acquire another entity. And so they didn't want to take on anything else, other than that, as they're going through this anti-trust scrutiny in their own state. But that strategy would have been to have one CEO, one CFO, and one CNO. In other words, one set of leadership for three hospitals. It would have been Springfield, Mount of Scotney, and Valley Regional in Claremont, New Hampshire. And in that particular scenario, the hospitals would decide between themselves who could deliver the services best. And because there was close proximity, that could happen. If you live where you live, that couldn't happen because you just don't have that geography that would allow that to occur. So each area of the state is unique and would be different. Right, and then I guess my final question is my concern also, along with Representative Houghton is the fact that the communities that they participate. I think that might be very difficult to get all of our communities to participate. And I hope that's something that can be done. Yeah, this is not something that's going to be easy. Yeah, so thank you Representative Page. I'm gonna just throw in a question here and or a comment and a question that this will involve some kinds of change, but there's not a plan. There's not a plan behind a black curtain somewhere that says this is the plan. And I think that that's, I think there's a sense of, there can be a sense of apprehension and fear that anytime you mention anything specific and everyone thinks about their own situation in terms of change. Like, well, what am I going to have to do differently? What are we going to, what's going to be different here? And I think at least my, I'm taking at face value that there is not a, there is a necessary based on the dynamics and the data that we see, there is a necessary change because change will happen. Change is going to happen regardless. I think that's the point I want to make. The market, as what you said, there will be changes, but they may not be the changes that we want. Changes will come because some things will not be viable. And we already see changes happening when hospitals are shedding a pediatric care or hospitals are shedding other kinds of care or we know that there's not sufficient mental health care because that's a low volume, it's a high patient value, but it's not a highly reimbursed fee for service issue. So I think we need to, there is going to be angst, but I think there also needs to be a sense of possibility as well. So, and the possibility is that there will be a system emerge with community involvement. And I think you're hearing that strong and clear. There needs to be genuine community involvement to actually move toward a system that we're not going to have the change that we just, we can't control or that we can't participate in creating. Instead, we're going to have a more, that we're going to work toward change that will benefit for monitors in the long run. And I think, I guess the other point I want to make is that I think you're, I think there's a big job here to frankly put forward why now, why is it what you're proposing? And so I think this is the beginning, I see this as a part of the beginning of that process, but there's a lot more that needs to happen to bring stakeholders to the table to be part of something as significant as this. And so I think there needs to be thought and planning about. We're just trying to figure out a way to get the table to bring everybody to. Well, I understand. And sometimes it's, which comes first, the table or the people wanting a table. So, well, I'll leave it there. I have some of the more specific questions and we'll find another way to take more time. I see that Representative Cordes and Representative Goldman have questions and then we'll see where we are. But I do want to respect trying to end shortly after 1130, if not at 1130. Representative Goldman or Representative Cordes, I think. Thank you. I thank you all for your, and I understand that and look forward to working together to create the significant change that we should be shepherding instead of allowing to have happened to us. I thank you for that. You're breaking up quite a bit. Perhaps if you dropped your video, sometimes the audio works better without the video, even though we're actually seeing you. Thank you. So understanding that, that I do look forward to working with you, with all of us and the community moving forward to shepherd these various changes. One thing I think of and have thought of when service have thought of often over the years is dialysis services. And I know that CMS now uses perspective. There's a reason you still can't hear me. It's really breaking up. We hear every few words, but I hear you asking about dialysis. I think we're going to need to come back to you, represent Cordis, because we're not hearing you at all at this point. Why don't we go to represent Goldman? I think you're back. Can you hear me now? I just switched to a different wifi system. Can you hear me better? Yes. Okay. So dialysis is challenging. CMS uses, the Biden administration is also looking at socioeconomic factors that impact equity. I, my concern is that we continue to ensure that people that live in Vermont have access to dialysis services. They are some of the most vulnerable patients that shouldn't have to travel long distances three times a week to receive those services. And I understand the, you know, hospitals often have to subsidize dialysis. I'm taking long pauses. Can you hear me? It's very difficult actually. I can, I can hear you. And I think one of the things I would say is I so appreciate that comment that you just made. And I think one of the goals here is to recognize that we're trying to move to a system that ensures access to essential services. Dialysis is essential service. And we need to have the system be designed so that people have access to it in close proximity when they need it. And so right now the system as it's designed may or may not allow that access for certain communities. And so when we think more strategically and intentionally about what communities need and we identify those voids, then we've used the payment model and the design system that we're thinking about to ensure that those services are delivered to patients who need it. And particularly a lot of this exercise should be about, a lot of focus should be on the most vulnerable communities who don't have often have a voice and may not have access to essential services. And we don't wanna export any care that we can do within the state. I mean, that's the reality. If anything, we would want to import care because we have high quality centers of excellent that are delivering care that people would seek out. So it could be economic development to bring people in. And we've based some of our NPR decisions in the past on the fact that for example, Southwestern was able to bring in people from New York and Massachusetts because of the failure of some of the systems that were in place in those communities. And we certainly recognize that and incorporated that into the decisions because any care that we can do in the state of Vermont should be done in the state of Vermont. Thank you for that. Thank you. I'm gonna go to represent Goldman and then I think we'll stop for the, even though I know there are more questions, we're gonna stop for the morning. Represent Goldman, you get the- I wanna thank you for all your work. It's really interesting and echo representative Potein's excitement about what we can accomplish when we put our heads together sort of starting legislatively and moving all the way down to the community. I think when we think about social determinants of health and chair Malini talked about prediabetes, I think we need to, I see that as midstream. The hospital system is downstream. It's the most downstream and most expensive part of our system. And moving as upstream as we can get is where we're gonna really keep people healthier. I think it's tragic that we're losing pediatric practices because that's where the most impact can happen. So it just may be sad to hear that and wondering how we can do it. We spend a lot of money at End of Life Care. There was an article that representative Burrow sent out about by Dr. Ezekiel Manuel about his father's experience at End of Life. I think it would be an important conversation of how we do that and how we make it accessible in our communities. So that would be an interesting topic. I think for me as policymakers, what do you need from us to support the transformation work besides $5 million? I would say that we would need your advocacy so that people can see that this is a concerted effort by everyone in the state to try to make our healthcare system better. And so bringing positivity to your own local communities and bringing information because Vermonters aren't following what we're talking about here today, but they might be listening to you when they run into you at the store or at a restaurant or so on. So that's what we really need from you is a full commitment that we want to move away from past failures and move towards future successes. So I hope that you all will be involved in those community conversations that we have when we do move out into the communities of being incredibly helpful to have you there with us, with the group of individuals who are leaving some of this effort to have you there at the table. Yeah, that's what I was going to add. I come from the sprinkle hospital area and have been following that very closely. Another, the culture versus capacity problem is huge there. So how do we make that shift? I'm interested in doing what I can to participate and support it. Thank you. And I would add as well, but it was a golden, and I've said this on numbers of occasions that we get to talk about this, think about this in a greater depth than our colleagues who are busy thinking about natural resources or thinking about transportation and climate change policy or thinking about other issues. And so part of our role as well is once we've vetted this sufficiently and feel that there's a way forward that we can support and that we do support, then it's also important, it's imperative that we are agents of interpretation and information to our colleagues within our own legislature as well. Because they're going to look to us to say, I hear these questions and those questions, what are you folks talking about? And I think that that's why I wanted to spend some additional time because I feel like we have not had yet that opportunity at the same level that I'd like us to. And this is now putting in front of us a proposal that's very significant and it will be challenging but very significant as well and an opportunity for us to continue to ask questions. So along the way, we just say we may very well want to ask you to come back. We have another whole set of questions to ask you as we try to get our heads around what this really means and whether and how we can be advocates for this. So I'm doing this up. Can I just ask a follow up to you actually if I may? Leslie, it's a very quick question for you. Yeah. I'm just curious and I'm new as you know, do we on this kind of thing that's so big that you ever take a stand as a committee? It may not be a bill, but would we come together as a group and say we want to support this? Absolutely. Absolutely. And one of the places that will be in front of us in the near term is a budget request. Great.  Yeah, and frankly, that's part of why I pushed hard to have us do this jointly because in fact that budget request is going to be in front of us very quickly and I was concerned that the budget request was ahead of the ability to actually understand what was underneath the budget request. And so that is an opportunity and not the only opportunity. Okay. So I'm gonna first, let me thank Kevin. Thank you, Kevin. Thank you, Jess. I'm gonna use first things. Of course, please do. I apologize, Susan and Elena. I think this has been very valuable this morning. And again, I think we have more we wanna understand, but and I wanna say, if I may, in addition to the presentation, I think that Jessica, the introduction that you gave, I found very, very helpful. I texted with Jessica to check in with her and she's going to provide a copy of that, a transcribed copy of her introductory remarks, which I think summarizes brings together in a very, very positive and powerful way the case that is being made in the presentations as well and in the full study. But most people are not gonna be reading a 68 page study nor even a 30 plus or 40 page PowerPoint. But I think the summary that you've put together Jessica as an introduction, I found very, very helpful and we will be posting that on our webpage and also making it available to committee members. Happy to. Thank you all for taking the extra time. I know we flexed and it was last minute, but this I think has been an investment worth making and we will continue to raise questions and ask for your input.


Myself Sachin Deshmukh working as assistant professor in the department of civil engineering of Walch instead of technology solapur today we are going to study regarding model analysis at the end of this topic students will be able to find out the dimensions of model as well as prototype depending upon the dominating force or dominant force particularly to study this model analysis we must know what is a dimensional analysis which we have seen previously every quantity can be converted into different dimensions that is we often we call this as a MLT system ML and T and many times again we are adding temperature also in that now why to study this model analysis particularly in hydraulics the structures are very huge take the example of dam canals wears then cross drainage works these structures are very huge if the structures fails there is a lot of we can say loss of property loss of humans many things will happen which are not you can say tolerable that's why before construction we have to go for their models and we have to study the model and then we can reflect those dimensions in the prototype now see in this introduction that many problems in fluid mechanics cannot be solved purely in mathematical methods as they are in complex signature just I have told you model analysis which is an experimental method can be effectively used to solve such complex problems particularly this study is for two important purposes to get the information about the performance of the prototype what is the prototype first prototype is a working model I will tell you once again in the next you can say in the next slide and the second one is to help in design and to avoid costly mistakes because these mistakes are very we can say effective mistakes and loss will be there it will cause and to evolve an economic solution of a hydraulic problem model is a model is a small scale replica not always small scale but particularly we can say it is a small scale replica of a actual structure or a machine and prototype is the working model or you can say it is a actual structure or a machine and the model analysis is the study of models of actual machine now see this is one of the photographs this is a model now how huge it is how huge it is we know the models or we can see the models are very small it is not like that to study clearly effectively models may be in large size also this is the dam see here this is the downstream side this is the upstream side very small details already they have shown in this particular model so what are the different advantages of model analysis the performance of the machine can be easily predicted with the help of the dimension analysis a relationship between different variables influencing flow problem in terms of dimensional parameters is obtained the merits of alternative design if the design is not properly working then the alternative design can be adopted and we can say the most economical and safe design we can choose for this we have to go for different similarities of model and prototype there are three important similarities geometrical then kinematical and dynamic similarities geometric similarity is related with the dimensions that is the ratio of all corresponding linear dimensions in the model and prototype must be equal now lm is the length of model bm is the width of the model l and dm is the dimension diameter of the model area is the area or am is the area of the model bm is the volume of the model then all these dimensions for the prototype is similar with lp then bp dp ap vp are the corresponding values of the prototype that is length then width then you can say diameter area and volume now the ratio of this length of the prototype to the length of the model width of the prototype the width of the model diameter of the prototype to the diameter of the model is denoted as lr similarly ap that is area of the prototype area of the model upon area of the model is lr square we know area is l into l that is lr square and it is a volume now volume of the prototype upon volume of the model is equal to lr cube volume is lr cube now what is the kinematic similarity it is a similarity of motion between model and prototype thus kinematic similarity is said to exist between model and prototype if the ratios of the velocity and acceleration at the corresponding points this is very important at the corresponding points in the model as well as in the prototype in same magnitude the directions also should have should be parallel to that is now see it is the velocity of the prototype upon velocity of the model of one is equal to velocity of the prototype of the second upon velocity of the model of the second is equal to vr similarly acceleration ratio it is a r that is in the kinematic similarity now most important again in this that is a dynamic similarity where all the forces at only before also there are inertia forces always there then we can go for gravity force viscous force then elastic force pressure force and surface tension force these six forces are very important and we are taking always one force which is more dominating force or we can say it is a predominating in one criteria one we can say one for one example many times different forces are acting on that but one force is we can say it is more dominating that force we are taking into account right now in dynamic similarity it is the similarity of forces between model and prototype thus the dynamic similarity is said to exist between the model and prototype if the ratios of the forces acting at the corresponding points in the model and prototype are the same in magnitude similarly and the direction is also parallel then the force in the prototype upon force in the model equal to like this there are different forces inertia force viscous force gravity force surface tension force pressure force and elastic force the ratio is fr now types of forces inertia force that we can calculate by rho av square viscous force we can calculate that is mu reserve dynamic viscosity u upon d into area gravity force it is denoted as fs it is rho l rho area into wells then pressure force that we can calculate by fp is equal to p into area surface tension force it is sigma into that that is the length organ say diameter and elastic force that is elastic stress into area these forces are very important and always one of the force is predominating force in that particular example now from the these forces we are going to find out different numbers different numbers now go for Reynolds number denoted as r suffix e it is a ratio of inertia force upon viscous force so rho vd upon mu so where it is applicable Reynolds number when it is a viscous force particularly in the closed pipe when the pipe flow is there viscous force is a dominating force so we are taking this viscous force definitely some other forces are also there i am repeating but this viscous force is more dominating that's why the ratio of inertia force upon viscous force we are taking for Reynolds number second Froude's number in the Froude's number gravity force is a predominating force gravity force is predominating force so the ratio of inertia force to the gravity force and we get the equation as v upon under root dg third is Euler's number here pressure force is predominating force so pressure force upon inertia force it is p upon rho v square if we want to take inertia upon pressure force then you can go for 1 upon this particular equation then Weber's number where surface tension force is predominating force surface tension force is predominating force so surface tension force upon inertia force it is surface tension upon rho v square similarly the final number that is a Mach number it is a ratio of inertia force upon elastic force raise to half that is v upon under root k upon p so these numbers are very important for solving the problems for the dimensional analysis as well as model analysis following are the examples where the study model study is used dams rivers and harbors where we can see there is a wear and tear regularly the hydraulic machines structures and ships ship models also these are some of the photographs of models see here it's a model of a dam here is a model of a river it's a model of you can say storage also we can find the capacity from this particular model here in the laboratory itself they have constructed a model see here it is in the laboratory and this is one of the big model of dam downstream side of the dam upstream or side of the dam then we can go for this from the spillway water is taken into the downstream side every idea is get cleared from these pictures see here the dam then you can see it is a river and it's a non the upstream side its capacity we can find out how the river behaves okay the mentoring of the river is also we can see here the model of a particular section dam is constructed in uh laboratory very many pictures are these are some of the questions for you take a look on this and write down the answers these are its answers these are the reference books


Hello, this is Bob Cooker here again from the Manchester Institute for Psychotherapy. This is a series of videos on supervision, clinical supervision, and we've been exploring the seven-eyed model by Robin Sherwood and Peter Hawkins first came out in their book Supervision in the Helping Professions, 1989, a fabulous book. Anyway, what we're going to do is explore this model. We're going to look at two particular parts of the model. One is to see how it's used as a grid for the supervisor and supervisee. And we're going to look at the different stages and modes in this interactive supervision process. We've done the first mode, which is about behavioral observation as a major focus of supervision. We've looked at the second stage and the major focus, which is all about contracts, treatment plans, why a therapist does what they do clinically and how the supervisor can help them without focus. And the last video we did was on the third stage, which was looking at the systemic process, the transfers onto the therapist, and how the supervisor, supervisee, by looking at the particular supervision in that focus can help the supervisor move forward. Okay, so now on to stage four. So this video, this clip with Roy Leokes again, taking the story further, is looking at the focus of mode four, which is the counter-transference of the supervisee. In other words, that unconscious part of themselves is often gets acted out, and it's very important for the supervisor to concentrate on, because it allows the supervisee particularly to explore parts of themselves which is outside their awareness, which might be hindering the therapy-client relationship. Okay, Doki, so let's move on to stage four. I've got Roy Leokes here again. Yeah. Thank you. That's great. I've really enjoyed these last three videos. Yeah. And now on to the next part, which is stage four, looking at your counter-transference. So tell me a little bit where we are with the story. What are the fifth sessions, I think? Yeah. Yeah. Well, the last time we spoke, it talks about kind of how angry the client was. And she's came up this time kind of deflated. They've now arrested her son. The son's now been arrested, rear-rested. I know. Gosh. Rear-rested. Rear-rested. And he's in custody. And she managed to communicate that he needs extra water and he needs a mental attention. So part of that is that she knows where he is, and I reflected that to her, so that she knows that he's getting the attention. He would tell me about the last Supervision session. He would tell me something very interesting, I thought, anyway, that we focused on other things. He would tell me about how angry she was. Yeah.  And then he said another interesting thing, which you may want to look at in this Supervision, which is your fear and just hypothesising how you are around women who express anger. And I thought we'd take that bit further and just explore what happens. Yeah. Perhaps, you know, he said you were, if I'm right, and you remember, he said that in writing your notes up, you were just reflecting on as a person, you know. Yeah. And when I counter how you are, perhaps with females that are angry, I was just thinking about counter-transfers and what might have been a vote there for you. Well, it's kind of interesting that, you know, being the age I was always brought up to think of men and women different in terms of anger. And that, not to put too far in the point, I mean, but women were the kind of sentient, weakest in my history. This isn't something I believe now I want to be talking about. No, I understand. But, yeah, but historically I was brought up. And as I grew up, women, I'm sure were angry, but they didn't express it. So your household, maybe that was the case? Absolutely. Absolutely. I have to say that my father wasn't a particularly angry man, but generally speaking I met a lot of angry men through my life, and in fact quite violent people. But I've never really met any very angry women, and it kind of gave me a bit of a dissonance, really, because part of me, you know, I could feel, you know, if someone gets angry, I don't know if it's the same to you, Bob, but women, when someone's really angry, it's managing that kind of adrenaline rush, because, you know, the part of the brain is expected next thing you'll be rolling about fighting. You know, I'm having to kind of manage that with this kind of picture that I've been painting of women in my history. It was quite, I had to kind of hold paradox a little, hold both of those, yeah. And how do you think you've got on in the session? I think I did very well. Oh, good. If I say so myself, I think that I knew immediately she wasn't angry at me, that helped a lot. She was angry at her son, and I was just the person she felt safe enough to express it. So, very quickly, I realised that actually she was, most of the time when she was speaking to me, she was luckily looking over my shoulder as if the son was still behind me. So, I know you're pretty astute, and it was really good to hear that you were able to hold those two polarities. Yes. Now, say, just for example, if you weren't being so good at holding those two polarities, what might have been the danger? I think the danger is that I may have run off. Like the son? Like the son. If it had been a man, the danger would have been that it could have escalated. It wouldn't have done, because I would have come to the same point. But as a woman, I think I would have run off. So, what could have happened? Is the evoking of this, you know, what could have been a vote? Yes. Is an early historical process? Absolutely. And then, what might have happened for both of you, of course, is there might have been a re-creation of history somewhere. I think so. I think it could have fallen into two distinct camps, but one would have been women aren't supposed to be like this, as I reached into my history. And also about the other way to deal with this is to avoid it.  So, in fact, I know that, as I said before here, you were a reflective practitioner, so you were able to hold those priorities. Yes. So you did something different by the sounds. Yes.  Is that right? I didn't initially, I worked with the theme of, I can see you're really angry, son. I wanted part of my work with her to let her know that I knew how angry she was with son. And even that, let her know that she wasn't angry with me. Right. So you did something very different from what I'm suggesting. Yeah. Often happens to supervisors. And supervisors are like anyway. So when a supervisor sometimes comes to my practice in mode four. Yes. They're bringing things outside their awareness where they actually play out a process which gets them a meshed off with their clients because their clients are evoking fragmented cut-off parts of themselves. And my job has always been to help them be aware of that. So it's nice to talk to you in the sense that you're able to hold those priorities. I'd like to think of it. I'd like to think of it. I'm sure that initially there may have been some leakage as I had to kind of settle that kind of process in there. But I think it helped me, if I'm honest, Bob, by saying I could see how angry we are with your son. Because by that I was taking away, I was diffusing the anger, wasn't I? I wasn't going to go around me. Yeah, you separated that as well. And so it was a good way of not getting caught up in account of the adjustments. Okay, well thank you for that. Thank you.