Welcome to Monet cafe. I'm artist Susan Jenkins and in this tutorial. I'm calling this painting sunshine I'm using some very bright beautiful pastels and only 18 colors. This is the unison set Curated by the artist Lucy Pittaway. Oh, we're gonna have so much fun If you would go ahead and like this video Go ahead and subscribe if you haven't already and if you hit the little bell next to the subscribe button You'll be notified of any future videos. I post this free video tutorial is brought to you because of the faithful support from my patrons On my patreon page for five dollars a month. You can support this channel and you get extra content So here we go. Let's talk about the supplies as I mentioned already about the unison pastels I was so blessed that unison gave me this set to do a product review And I was so so blessed to be able to learn more about artist Lucy Pittaway So these are 18 colors that she selected from unison pastels and when I first saw them I was instantly happy because the colors are so bright and beautiful now her style I'll talk about more in a minute. It's rather whimsical and fun I always do this when I get a set of pastels at least I do now and when I was a beginner artist Sometimes would forget but I like to make a mark and write the color down so that if I run out of a particular color I know what it looked like and I can order it from that number and Let's go ahead and see on unison's website You can click under their artist section and read a little bit more about artist Lucy Pittaway She's absolutely beautiful and when you read a little bit more about her you can see she's beautiful on the inside too Like I said, she has a lovely whimsical and fun style and here it says she has two dedicated art galleries Also, she is a former graphic design teacher. I majored in graphic design myself It also says that Lucy chose bright and uplifting colors for her artwork And each piece has an underlying story and inspiration related to her own life family and surroundings Lucy is really well known for her sheep collection Her work just makes you feel happy and don't we all need that of course you can find it on the unison color website But I found that it is a little more affordable on Jackson's if you go to Jackson's art supply, I can't remember the website for it, but it's only $79 there the surface. I'll be using is pastel matte. You can find that and so many other products on my Amazon shop page Simply go to I have the link in every video go to my idea list where I'm clicking there and they're sub Categorized if you go to pastel papers and more These lists move around when I add things but right now it's the last list At the bottom there. So it has many of the pastel papers that I use. I love using pastel matte It's the second third and fourth one there I use the colors sometimes but in this lesson I'm using the white pastel matte I wanted this painting to be bright and in line with Lucy's style of happy and cheerful and Also, too I'll be doing a watercolor underpainting and I have a list of Watercolor products that I like to use and recommend as well So you can check that out if you like and that's it. Let's get to painting first I am going to create an underpainting with watercolor I got my sketch in with some charcoal pencil and I loved these sheep I found the reference image on Unsplash.com. Thanks to photographer Francesco Ungaro now I did crop the image and I flipped it horizontally I just liked it better that way if you're a patron of mine You will get my cropped and edited photo to work from I also did a quick little study of one of the sheep on a piece of pastel matte I like to sometimes do a little preliminary piece just to get started now again I'm doing a watercolor underpainting because pastel matte is water-friendly. I often like to put my watercolors just in a plate I like a circular palette much like the color wheel. I have ultramarine blue Prussian blue. I also have cadmium yellow and I have another yellow kind of color. It's called quinacridone gold. I love it It's a really kind of gold and yellow color. I also have quinacridone violet now with these five colors I was at five one two three four five. Yes, I can create so many colors. You know how you can mix the primaries So really with watercolor, it's awesome. You don't need nearly as many colors as with pastel I love to use these Princeton brush company brushes. This is the 4050 round I used a 10 and an 8 I believe maybe no I think I just used the 10 I did use a bigger brush though to lay down some water Here I'm mixing two different purples the quinacridone red and the ultramarine marine blue and then the prussian blue with the red It makes two different types of purples now I'm mixing some yellow orangey colors And then I'm mixing the quinacridone gold with the red for a more brilliant orange and two greens the prussian Blue and the yellow make a more cool green the ultramarine blue and the yellow make a warmer green So with these five colors you can get so many combinations now I thought I'd just go ahead and lay in some big areas of color for an under painting now This is going to be one of those videos where I say do as I say not as I do I've done watercolor on this pastel matte white surface many times But I never actually tried to do it in this way where I was sectioning off areas And I didn't realize how much it bleeds into other areas. It's not quite like watercolor paper This was something I learned I I got it all bleeding down into my sketch that I did So I ended up just not even worrying about it and just getting in the big blocks of color And I kind of lost my sketch because of that. So if you do an under painting on pastel matte You might not want to do it in this way What would have been better probably is for me just to get in some some nice color and then put my sketch on top So what I'm doing though you get the general idea Same principles apply to so many paintings. I'm just getting in big blocks of color I'm covering up that white surface with the general big shapes Values and colors and you can see it it was bleeding all around the edges now It doesn't matter that much because I do cover it up with pastel Again, keep that in mind if you're doing something similar on pastel matte and now the fun begins using these brilliant and bright Pastels I started with the lightest green. This was a sunny sunny day That's why I call it painting sunshine and I even named the painting sunshine days They were just these cool-looking sheep walking down the road in the sunshine now I have put up the reference image for you to see while I'm painting. I apologize that it's so small I have to wrestle with do I want you to see my pastels and A small reference image or blow the reference image up and then you can't see my whole palette So I thought you might like to see the pastels. I'm choosing in this one now. I did switch to the middle green here I'm working kind of like the way color works or value I should say works usually darker in the foreground and gradually getting lighter in the background I'm keeping this super super loose now. I'm working on that shadow the only real dark Well, there's two sort of darks this dark green that I'm using here I'm just kind of getting in that shadow. You can see in the reference image there the shadow was on our left side and Now I had to work in a little bit of that green between the legs like I said I really lost my sketch. So I had to just kind of Re-paint it which was fine and one reason I really like this image is because I felt like I could utilize these colors In this set quite well again bright colors. They kind of look like sunshine and the photo was Very bright and sunny It was so easy to see where the light was coming from from our right shining onto the sheep from the right now I used a pastel pencil if you've watched my videos much used no I don't often use a pastel pencil, but I kind of used it to resketch in To re-establish my sheep. So it was no biggie. I just redrew them So now I'm using something. I'll show you an image of it later. It's a pastel blender made by Pan Pastel So I'm gonna I'm gonna use one again and in just a little while now What I'm doing now is what I talk about in so many painting videos I'm focusing on value the lightness or the darkness of something and the advantages of using such a small set like this is you are forced to Rely on value because you don't have some of the colors you need sometimes So you have to just go with what value is correct versus color and this middle topi color. It's kind of a Brown topi color was nice for some of the shadows of the legs Now I noticed that of course the sun's coming from the right and so the right side of the legs are going to be more In sunshine the mother sheep though the middle sheep was kind of in front of her So the leg I'm working on right there was just catching a little bit of the sunshine and that one was almost all in shadow back there So these are just little subtleties that you pay attention to while you're painting and you you just choose values that are close I think working from a small set is so great Not only for beginner artists because you know sometimes we don't have a lot of pastels Or we can't afford to go out and buy hundreds of pastels But I think this is a great exercise for Pastel artists that have been painting a while It sort of reestablishes the importance of value and also how we don't always need so many pastel colors I'm sorry. Yes. I am actually admitting that. I know we always want more pastel artists. I get it I do too, but sometimes we can overdo it We don't really need as many colors as we think often. So I'm using this is the other dark This is the dark blue. It's probably the darkest of all the colors and the dark green would be next and I'm just scumbling in kind of giving directional strokes to the Shadowed side of the sheep. Now what I'm doing here is like, oh my goodness. Why would you use that red? Well, what do red and blue make they make purple? So I'm using this blender I did say I would talk about this blender These are the pan pastel soft blending tools and the one I'm using right now is the one that says point It's the bigger ones and I find that these blenders or sponge bars They're called work great on pastel matte. Sometimes if you're working on a sanded pastel surface That's very gritty. Sometimes these don't work as good, but in general pan pastels Work great on pastel matte if you're not familiar with what they are. They're literally like little pans They look like little makeup compacts with pastels and you can use these blending tools to paint with them Like you would an acrylic paint with a paintbrush and it's really a lot of fun I got to pull mine out again and do another tutorial, but this pastel matte surface is great for that So I'm using the blending tool here. You can see I'm picking up some of the blue I had before That I painted on the mother sheep and I just drug it over It keeps a little residue on it so you can kind of get in a little value study All right. Now I'm just getting in this road with some of the middle Um tan color that's in the set And remember that when you're working with pastels or really any medium Don't feel like you have to get everything just perfect at first It's all about the layering And keep a light touch and just get in the layers and usually I work dark to light I'm not even going to try to put in any of these bright Sunny looking Parts of the wool on the sheep Because if I try to put that down right now see the sheep are still pretty light before I added that orange color If I tried to put light on light, it's not going to show up. You've got to have some color contrast Okay, I added some more of that orange to the legs where the sunshine is just in the areas If you have a big enough screen, you might can see the sheep or you I'll put the reference image link Um in the description of this video if you want to pull it up Now it's going to be flip-flopped so the sun will be coming from the opposite side But if you're a patron of mine again, you'll get my cropped and flipped image So now I'm going to the lighter yellow again getting gradually a little lighter Getting that sunshine on the sheep now sometimes this it looks kind of crazy at first, right? But really it does all come together and hey, this is art. Okay. We're not always trying to Really very realistically portray our subject matter This one actually came out Pretty close to some of the colors because like I said, I I found a photo that happened to work with these pastels Um, so, you know, just if you are a beginner artist and you have limited pastels Focus on value and you'll be on the right track. So now I'm just adding The middle blue it with the blues in this set There was a dark blue then there was this middle blue then there were two lighter blues Um, the one next to the blue and I'm working on now is a little bit more teal It's light, but it has a little bit of a cooler color to it And the other one is the lightest light. Well, it's not actually the lightest light in the set Um, the lightest light in the set is actually it's like a white It's a warm white and then there there is a black. I don't think I use the black And I often don't choose black for my paintings, but I do have another tutorial coming soon Where I did a painting using this set, but I limited myself even more I think I might have only used I don't know 10 colors maybe and that one will be on a new surface I had never tried before and I'm very excited to share about that So if you haven't subscribed to this channel, go ahead and subscribe So and and like I say hit that bell icon because that way you'll get notified when I upload something new And by the way, this is sped up only slightly just to reduce the size I actually find the times when I know a lot of guys are like real time real time I find sometimes when I upload a video that's real time if my videos are over an hour um, I can tell from the youtube analytics That they people just stop watching. It's like everybody's attention spans have gotten shorter So I'll I'll sometimes have more real time on my patreon page as an extra Um, but often I'll just slightly speed it up because usually you can you can see what I'm doing here I mean and you can always pause the video. So now I'm using that topi brown now the sheep. We know his her I'm assuming this is the mama sheep Her fur even though it's on the cooler side where I'm working now It's still, you know, kind of got some warm tones in it So that's why I chose to use some of that topi color now There were some little highlights where the sun was catching just a little bit of the back side there So I didn't want to overdo it. You don't want to add too many light values on this side But it was almost like it was a little bit of backlight Um, and then I blend some of this in too so it doesn't look quite so light So just working a little bit of the lights around the perimeter Of the sheep now I did love this little minty green I think I'm going to zoom in a little bit so y'all can see a little better Like I said, it's it's very light, but it's just got a hint of a teal color to it So it's kind of a warm Light color and I found it was a good color just to catch some of those highlights On the underside of the sheep and the reason I chose that versus white Is it was a little bit underneath the sheep? So it was still a little bit in shadow and that means that colors cool off a bit So the lightest light I'm not sure if I actually I don't think I used the white But I used one of the lightest lights that was that warm White color I finally add at the very end to the sheep Their faces again if you can see the reference image you see that the Our right side of their faces is the lightest light where the sun's hitting A little bit on some of the legs the ones that are sticking out the most And then also a little bit on some of the wool some of the little curly cues of the wool So again, I'm having to focus on value here and I didn't want to just add white to their face This was a lot more interesting and later I'll come in and add a little bit of lighter what I'm calling white to this as well So you can see how I use this minty green and this makes painting fun Like I said, we're artists. We're supposed to have fun with color and by limiting yourself with colors It forces you to choose fun and creative colors. I have that question all the time How did you know to choose that color and um, sometimes it's just knowing a little bit of Rules they're not hard with color temperature and just how color behaves That you can choose colors that you don't necessarily see but sometimes if you limit yourself with your palette you can Get creative with color by your force to you know by necessity In this angle of filming and the way I cropped it I was able to get this sheep reference image a little bit larger. So hopefully that'll help now. I'm adding a little bit of this Kind of middle Tan color to the mama sheep. She was a little bit more in shadow and I'm adding That lighter tan. I guess you would call it's in the row of the those topy colors the lighter one to the right side of the sheep here and you really getting that feeling of sunshine now and And it was just fun. This it just looks so bright and cheery to me I really enjoyed painting this and I enjoyed the results because you know, this isn't my normal style of painting either so I have to say a big thank you to unison for gifting the set to me to be able to do this demonstration and Learning a little bit more about artist lucy pittaway. I would love to meet her. She's got this beautiful english accent I saw a video on her. I don't know if it was on the unison site Now I'm adding a little bit more of this orangey color Warming it up if you look at the reference image and squint your eyes. You can see there really is some of that orange feeling to the sheep and now the the left side I keep Getting confused with that. It's the sheep's right side, but it's our left side Is really in shadow. So I'm even adding more of that blue. So what am I doing now? Oh my goodness. Look at that bright bright. This is a gorgeous red by the way That bright red that I'm putting in their ears. Surely their ears aren't that bright red. Well, no, they're not but this is one of the Aspects of pastels that you can use to your advantage with a limited palette. I really did love this orange color Sometimes with sheep and with pigs certain animals if the sunlight is shining in their ears behind their ears It really does illuminate some areas to be this pretty pinkish orangey color So even though I laid down that bright red. I'm like I said, I'm using the Ability of pastels to layer and kind of alter colors by some layering now I'm just I'm kind of outlining the ears with some of the the way the sunlight was capturing The little fuzzy fur around their ears, but you'll see me go in with other pastels Like on that mama sheep, you can see the left ear our left is darker inside. I go back later with a darker blue or some of those blues and I make Little value changes to that now. I am using you saw me use that. I think I was using that blending tool again Now I am going in with the pastel pencil and kind of getting in some of the darks of the eyes I wanted to get them right and The pastels were a little chunky for getting some of these features just right So I wanted to kind of reestablish the darks there now. I actually use the pastel pencil I use that instead of a pastel to kind of darken that center part of the the mama sheep's ear and same thing here you see how I'm just Changing some of the values and leaving a little bit of that bright color at the tips of the ears And now I am Going to be continuing to layer. I've got the basics in I've got color down everywhere And I'm going to continue to layer the fur and establish the values and colors further So I've got about at this point. There's probably about Oh 17 more minutes 16 more minutes into the video So I'm going to add some music But I want you to pay attention to how I'm I have I've resisted the urge to put in the fur I've just been putting in large shapes But now I'm going to gradually start adding some of the fur Would you call it fur wool? Whatever you would call it on a sheep Reestablishing some of their faces the baby sheep need their faces Really finished too, but just kind of watch that layering process And don't go anywhere because closer to the end I'm really going to zoom in so you can see a lot of the detail in the strokes And how they really do look like they're glistening in the sun by the end of this. All right. Enjoy the music And now we're getting closer to the finish line. So here I've zoomed in And I I hope you can see how bright and sunny they look and I I really loved this fun Exploration with this set and limiting myself with these colors And it is truly proof that you don't have to have a million pastels to create a painting And I always recommend getting quality over quantity when it comes to soft pastels Don't get the cheaper pastels just so you can get a lot of colors That is one thing that's worth it is the quality Professional pastels because the ones you get it like the craft stores You're just not going to get this kind of color. So you can see I added in some grasses now I'm working more on that shadow. I wanted to I added the darkest blue for the shadow But I softened it with that medium blue and it kind of softened the edges and took down the dark value Just a little bit. Now I'm going to add just a little bit. The road was just kind of really flat with one color I did want the sheep to be the main focal point But I wanted to give a little bit more color to especially that area underneath them And this is also a lesson in stretching yourself artistically to paint subject matter You don't normally paint. I mean, I might paint sheep, but I wouldn't have done them this fun So I really do love this little painting and I will have it available in my etsy shop soon And I'll probably make prints of this one on my fine art america print site. So check that out I hope you learned a lot. I hope you'll subscribe if you haven't already Find our facebook group the mone cafe art group on facebook Become a patron if you'd like to support this channel and as always god bless and happy painting


So, to me, that's why I travel around. That's why I love to come to do these gatherings. Because I'm having an experience that there are no problems. And I'm very happy. That's why I've got a big smile on my face. I laugh a lot. I sing. I burst of singing at times. I go skipping along in nature and everywhere. Because there's experience that there are no problems. But all the problems have already been solved. The spirit has solved them. And then when we come together, we are joining our minds together to come to that experience together. So if someone believes they have a problem, believes they see a mistake, believes they see an error, then let's look at it together, honestly, and see if that's really true. I would say, honestly, that none of us have a problem right now. All problems are either remembered from the past or anticipated. There are either regrets of the could have, would have, should have. Things could have been different. And, oh, my life would be so great if this had only been different. It's all these regrets or worries and concerns about the future. Which is really just the past projected onto the future. Keeping us from the now. And so when we go much deeper into that, we come deeper into the presence. We come deeper into guidance. We come deeper into our intuition and to an experience that there are no problems. It takes a lot of trust and faith to go for that because there's a part in your mind that's convinced there are problems. And our educational systems and all the gyrations that we go through are all based on this belief that there are problems in the world that we have to solve that deny the perceptual problem. Like looking through a cracked lens and not seeing clearly.


Good morning Hank, we're at the Louvre and with the help of my intrepid spouse, we're going to determine which artists have seen a baby. At first we weren't sure how to get to the Louvre, but we figured it out from context clues and after marveling at the crowd for a moment, we dove right in to determine which artists have seen a baby, which this artist totally has and this artist totally hasn't. And yes, I know that cherubs are not technically babies, but we all know that in order to make a good cherub you need to have seen a baby, which sadly this artist has not. The sculptor has seen a baby, although babies do not tend to have a waist, so that was a bit of a weird choice. Side note one, by the way, there will be three side notes. These ancient Greek and Roman sculptures in these galleries seem inevitably unpainted emphasizing the texture of the marble and whatever, but in fact, most of them were painted, often very brightly, meaning that our whole neoclassical architecture and art thing with unpainted stone everywhere is not actually neoclassical. Anyway, Jean-Louis David has definitely seen a baby, really good baby. Botticelli I think saw a baby once years ago, but he's never seen a baby throw up on anyone. I actually think Paolo Veniziano has seen a baby and has seen a baby more recently than he has seen a human woman. Then I went into the Mona Lisa room to look at the people waiting to look at the Mona Lisa. Recently, for me, I'm not here to see the Mona Lisa, I'm here to see if Titian has ever seen a baby, which he has. Lulilene also has seen a baby, whereas Domenico Bocafumi most certainly has not. He's never even had a baby described to him, he's just seen adults and imagined that they were once smaller. This artist has seen a baby, or at least a black and white photo of one. Then we have this fascinating painting. One thing you should know about this artist is that he has never seen a baby. Oh wait, I feel a side note coming on. I can already hear the art historians screaming, homonculus, homonculus, which means like man-child in Latin, and it was this big thing, especially in medieval European art, where people would paint the baby Jesus as simultaneously small and a full-grown man. Here is a particularly horrifying example, with the idea being that Jesus was always 100% God and knew everything even when he was a baby, and so we have to portray him as simultaneously a tiny little baby and a God-man, none of which changes the immutable reality that this artist has never seen a baby.  This artist has also never seen a baby, who are in fact notoriously poor horticulturalists. Also, this artist has never seen a baby because they cannot hold books above their heads, but this artist has seen a baby because gosh, they look good in hats. In grade note three, I was utterly entranced by this incredibly weird painting of a young man holding a statue, like the way he's holding it is so weirdly loving, but the man's face looks like he just got dumped or something. I don't know if this is a good painting, but after all this religious iconography and mythology, it was just nice to see a 400-year-old Michael Sarah cradling a statue. Alright, back to the baby art. This artist has seen a baby, as has this one and this one, and Rubens is so proud of having seen a baby that he painted like 30 of them, but of course, this artist has not seen a baby, and frankly, I hope he never does, because I do not think you can trust people who think babies look like this. After looking at all these cherubs and baby gods, I was starting to think there wasn't a single work of art in the entire Louvre that understood anything about actual babies, but then I came across this painting with sweet little babies floating in space surrounded by flowers, slightly spirally, but also lovely, and I finally felt like my journey had come to an end. An artist who hadn't just seen a baby, but may have even, like, held one. Hank, I'll see you on Friday.


Soldiers of the headquarters and headquarters battery of the 75th Field Artillery Brigade organize and execute efforts to qualify personnel on the M17 Weapon System. You know, obviously working through four-still range of operations and everything is very supportive in everything we do and make sure that we're able to do the best type of training as real and professional as we can. The M17 is a 9mm short recoiled semi-automatic pistol. It has a 17-round magazine capability and a range of effective fire up to 50 meters. Located at the Automated Combat Pistol Qualification Course, or CPQC, the soldiers conduct preliminary marksmanship instruction, which allows for familiarity and acts as a range rehearsal. The support of an ammunition detail allows qualifiers to stay focused on their mission. Professional personnel are on standby and communication equipment ensure a high level of readiness. Staff Sergeant Montgomery is the tower operator. As the eye in the sky, he controls the safety and operation of all activities on the range. The range stays live and concludes only until 100% of personnel assigned have qualified. Captain Sherpac shares his expectations for his battery. That's across the board.


The following is a production of New Mexico State University. Of the many publications produced at New Mexico State University, probably the best known is the student-operated newspaper, The Roundup. In the early years of what was then called New Mexico College of Agriculture and Mechanic Arts, the newspaper reflected the flowery, journalistic style of the times. Major events were reported, including commencement of the first class, the transformation of New Mexico from territory to state, and the presidential visit of William Howard Taft to Las Cruces. Sports was always a popular topic, lauding the valiant efforts of Aggie teams in triumph and defeat. Today, The Roundup boasts a computerized operation with a circulation of 14,000. For the early years, I'm Carla Aragon. This has been a Centennial Celebration Minute from New Mexico State University. The preceding was a production of New Mexico State University. The views and opinions in this program are those of the author and do not necessarily represent the views and opinions of the NMSU Board of Regents.


Hello and welcome to the session. I am Deepika here. Let's discuss a question which says Consider the experiment of throwing a dime if a multiple of three comes up Throw the die again and if any other number comes toss a coin find the conditional probability of the event The coin shows a tail given that at least one die shows a three So let's start the solution Now we have to consider the experiment of throwing a die in which if a multiple of three comes up We have to throw the die again and if any other number comes up Then we have to toss a coin now the outcomes of the Experiment can be represented in our diagrammatic manner called the pre diagram So here when we throw a die any number from one to six can appear So if a multiple of three comes up that is either three or six comes up Then again we have to throw a die But if any other number comes up that is if One two and four and five comes up then we have to toss a coin So from this three diagram the sample space experiment May be described as is equal to One h one t three one three two three three four three five three six four h forty five h five t six one six two six three six four six five and six six therefore the sample space s has 20 elements now we have to find the Conditional probability of the event the coin shows a tail given that at least one die shows a three so let E be the event that the event one die shows a three consisting of elements one t two t Four t five t and f is a set consisting of elements Three one three two three three three four three five three six three now Here we observe that e intersection f is equal to five Therefore probability of e Intersection f is equal to zero now according to our key idea we have probability of e upon f is equal to probability of e intersection f upon probability of f Provided probability of f is not equal to zero since probability of e intersection f is equal to zero this implies probability of e upon f is equal to zero Hence the conditional probability of the event the coin shows a tail given that at least one die shows a three is zero So the answer for the above question is zero This completes our session. I hope the solution is clear to you. Bye and have a nice day


This paper presents a novel approach to studying the genetic make-up of the white fly, Bemizia Tabachi. The authors use short read sequencing technology to generate a massive amount of data from the white flies transcriptum, allowing them to identify thousands of genes and analyze their expression patterns across different developmental stages. This data will be useful for understanding how this pest adapts to its environment and how it can be controlled. This article was authored by Zhong Chuon-11, Baoyang Yuan, Li Zhenminet, and others.


Well, I wanted to know if it was a good back to LTA, just how this is the end of the LTA. It was not. I mean, next week, to answer your question all seriousness, next week we have the mandatory minicamp, which is good. You get the physicals on guys, but it'll be the exact same structure. It's not like you can put the pads on. It'll be the exact teaching, development, guys are doing a good job. You've had some speed in 7-on-7, and things we're doing as a team. We're not in full contact. Again, I don't know if you saw this when you were on vacation, but another team got in trouble for contact. That's not what we're about here. We're trying to build up and make sure we're ready to go going in the summer, so we can be full throttle starting July 26th. So the next week's format is very similar to what you've seen today or what you've got seen in the past. Yes, sir? We'll use all three days. We won't use the same format, like strut, you know, day to day. We may do something on Thursday. It won't be any kind of surprise, but we won't do anything ridiculous. I just heard teams use more than a lot of states like a team building. Sure. I mean, a team building more to me. It's more, hey, appreciation. It's a building. We did a team building exercise, quick, funny story. Not to call it a run, Andrew. We did a paintball as a defense in 0-7, and he got hurt. He got hit in a spot and actually missed the minicamp. I don't know what I'm allowed to say and what's not. Comical. Luckily he was all right. So I've always stayed away from paintball so nobody gets hurt doing any kind of team activity. All right. What else you got? Can we get the red helmet comment? That was pretty absurd. Yeah. That's the whole history on that. Yeah. It didn't hurt Pittsburgh, right? They wore the 1960s. Well, in the 62 when they did not win, right? They wore the yellow helmets. I think they changed after 1962. Chuck Noel got there in 1969. I don't remember their money before that. Certainly didn't hurt them in 0-7 or 0-8 or 0-9. I'd have to ask Mike Tomlin if that really impeded their Super Bowl progress. Wearing a helmet of a bygone era. So I can help us win. I can help us lose. If we didn't have marketing, the game wouldn't be where it was today. With a good product, NFL films, we wouldn't all be rewarded with the jobs that we have. Next question. Good question. Do you find minicamps a lot more productive than, say, an OTA? What can you do in a minicamp that you can't do an OTA? It's not any different. It was the way the rules were.  But where we're at in today's climate, we're not going to do that. Our guys are doing a really good job. A lot of stuff we're doing not only on the field but off the field in the classroom to strengthen and development, strength training and development. Pleased with the progress. We know we got a lot of work ahead of us. So no. So it's not like you can get your messaging across any better or anything. It's a build up.  We work on messaging every day. So I could be some 1-1-1 for the Gipper speech on Tuesday or Wednesday. It's a constant message. People want to talk about culture and things you want to cultivate. You got to work on that every day. Do you have 1-1 for the Gipper speech? I'll make it. You want it to me. Depends. Maybe D-Led can give me a topic and I'll get you guys one. Power football. Any players who are off season stuff that we're not going to be doing any those guys won't be out in the field. I mean, it's not like I anticipate everybody being ready to go by camp. Other than, you know, we'll have to assess. I say that with the ashric.  You know, Isaiah Oliver, John Fitzpatrick, but everybody else that had things cleaned up. I would anticipate again, there's a lot of unknown, you know, guys are out of here for five weeks. I would anticipate everybody being ready to go by camp. Will even guys who can't practice next week or be on the field next week be here? Yes. Yes, they will. So you don't anticipate no-no shows? No, I do not. If there's a surprise or something that's not, I'll be happy to let you all know. When you're using, when you see now, when you see next week, you can't evaluate shit, right? Do you, does this count the same to you as when you're evaluating, say, a quarterback or maybe some new roster spots? Like is it, that thing where every rep matters or once camp starts, is that weight, is that weight? What really do matters, I mean, you have a purpose while you're out here. It's just a different evaluation. A lot more of it right now is mentally. You know, you're just building it up. I mean, everybody learns different ways and the act of doing, it's the best way to learn for anybody.  So the pockets, you know, that's not a fair evaluation.  You could try to simulate that stuff with some different props, but it's not the same. But it's just part of the buildup process and that's why I get excited about preseason games, joint practices and the buildup to the, to the revenue season. Is there something too, like when you have, say most of the rookies working with, like, kind of their peers, we'll call it, and then you'd have a guy like Drake working maybe with some of the more vets. Is that just to... We've done it. We've mixed and matched. I mean, you've seen some days and whether we've done it with the DBs or the receivers, maybe there's certain things we've installed or we want to, we want to give everybody a chance to work with all the quarterbacks or I think that's important. That certainly pays off throughout the year, you know, when you're dealing with injuries and different guys up.  You kind of rotate them all every day and the guys that are kind of separate themselves in the pack, they'll take more first team reps. But I've never got a problem if a position coach wants to reward a guy or they have a good rhyme or reason to mix and match personnel groups. I didn't pay them all though for you, by the way. I didn't really well. I think I, I can't remember. I may have been the last out with either Sean Springs or Fred Smoot, I can't remember. I think I got Smoot. I think I did. Again, it's been a while. Charles. Good talk. Great. There, there's lots of new faces. That inside linebacker group with Evans and Kukowski. Just get quit. Like how are those guys coming along mentally and kind of learning? Yeah, they're doing a good job. Like I said, I've said it many times and all those guys in there, it's going to be a tough group to make decisions on really. To be frank, assuming, you know, they keep progressing and we think they will. What it also does is it give you an opportunity if a lot of guys can help you, you can create different personnel packages. So that we don't offense, Dean does a great job on defense. And if a guy's a good player, we'll find a role for him. When you have a completely new, you have a couple of position groups that the room's almost completely, yeah. How does that differ in terms of how you approach this versus one? And maybe that, or do you have three or four guys who worked with you last year? Is there a difference in approach or is there a difference in how that goes? I mean, I don't have a difference in approach. I think what you want to make sure is you never get stale. And that's the thing, that's why you get guys credit that can play year after year at a high level. Because it is competition. And I understand guys that are compensated differently and there's an expectation when you're compensated. But the day you've got to earn a job and if a guy's playing better than somebody else, you better have the backbone to play the better player. And I get the different dynamics. But if you do have experience in a room and it's guys that you value, you may not have to, you'd hope they can lead the room a little bit better. And maybe the position coach doesn't have to, he can adapt year to year, phase to phase. But the approach is the same. You want competition, you want a whole guy's accountable and you want to improve. Can a second year guy like Audie theoretically do that? In terms of what? You talking about leadership? Or when you're building that room because the A direction room is really the only holdover from a year? Yeah, I mean, you got different experiences. I mean, Lorenzo, I mean, he's played a lot of meaningful snaps in the NFL. And Audie, you know, guys continue to learn year after year, but there's probably some experiences he can pass on to D'Angelo and Arnold Ebacate where, you know, hey, this is what I went through as a rookie. But in terms of leadership, I think that naturally happens. You know, when guys are productive and they got good habits and, you know, it's I think the locker room, you know, really, really, the true locker room separates who's really the leader, not who gets posted on Instagram or, you know, who has a good PFF rating or the number of Twitter followers or Instagram, whatever. I mean, they're just kind of like ramping things up in OTA, but has there been anyone that's come in that's maybe impressed you with how they've been in shape or has done anything in OTA that's really stood out to you so far? Yeah, there's been several guys. Yeah, pleased with both the quarterbacks, what Marcus and Desmond are doing and Felipe is still working in the room. Felipe is a valuable football player for us and he'll take some reps at quarterback, but I put Felipe, you know, in that hybrid category. Yeah, Damir Byrd or Hodge, those guys that, you know, in this setting, again, we got a long way to go. I've been impressed with them, the guys I hadn't worked with before. I like if Fetty's work habits, what he's shown so far again, we're not in real pads. There's been several guys that have started to, that you notice, Dean Marlowe, so it's hard with the front guys, but guys, you know, you just, you appreciate their approach every day. Terry said in a radio interview the other day that the final 53, he doesn't think, or hear right now that there's going to be some changes. How much, how many changes, or do you expect changes once teams start? Yeah, I think it depends, you know, some things that are, you may intentionally try to do that they can be out of your control. I've never subscribed to your 53 set, like we're not going to have some pizza party to final cut down day, and here it is, everybody here's your scholarship for 2022 and work that way, you're continually trying to add, and we, as you guys saw last year, we found value during season and that's why I appreciate our football staff and, you know, some years it may have been more active than others and there may be an opportunity that comes across, you know, some, I like to say some trends, some trades could be a win-win, like you hope the Brian Evers trade, then always have to be zero song, like happy to work with the Raiders and hopefully it's a good situation for Brian, he's a good player and fits maybe what we're trying to do right now, but you never know, those things come across and you may not be anticipating and somebody calls and you're going to always look, so I just never look at the roster ever being set, ever. Do teams around the league look at OTAs in many camps and think, okay, I don't know if we have what we thought we had here, let's go out and get somebody? Not necessarily you, but I think teams do. I mean, I think everybody, you know, everybody's so optimistic this time of year, I think they've got a great 90 person roster. I think you evaluated the pins, you try not to overreact in spring. I've seen that before, you put labels on guys, you just call it the king of spring and then they disappear, you put pads on, so try to be objective, but yeah, I think that's pretty common. So you and these friends would be getting phone calls here between now and training camp? Yeah, and that happens and that's really pretty common, but in my experience with the personnel guys, those guys talk all the time, they talk to each other and it's a pretty stand opportunity, I think it's, I don't know, and again, I'm not trying to be a smart out, I'd be led, but I don't know how much the GNS of yesterday here used to talk, but I think guys today talk a lot more. Okay, so there we go. And last one on this, even with cap issues that you guys may have, potentially there could be players cut from other teams that would fit into the way you would. Absolutely, yeah. Those are things you don't know and it happens and you take a look at it and hope they can improve your team. You said you feel like this is a build up OTAs and mini camp, but what in your opinion makes a successful OTAs? Well I think a couple things, you feel better at the end, which we do and we get a couple more opportunities coming up, but you would have that people have a better understanding of how you want to play that year, your playbook, your insulation and what kind of shape they're in and I think that's what you can evaluate and you hope that we've improved as we started on April 19th and so that's where you kind of measure progress. Let me, I have a couple questions for you when you start off with the football question. So we keep talking about the fresh faces, the younger team but I was talking to Dean Pease a couple weeks ago and he was saying how I asked him how much more comfortable he is, right? Because now you guys are going into year two and he said now I feel like we can just go without thinking, without teaching. I want to know about your coaching staff today as a whole and more comfortable? Yeah, I do. I think, you know, we we're constantly looking to improve our staff as well and guys have other opportunities like Chandler and Emily had an opportunity in Miami that I wasn't going to block them, which could have been a ladder, you know, proceeded a ladder to move but so opportunity for other guys but most part, we got most of the coaches back and it just helps with more communications, like building the team in some aspects, the team of it and me, what can I do better because I have a better understanding what, that maybe I'm asking you haven't worked together before or you haven't worked together in a couple years and say anything with Dean and Marquis and Dave, so I do that's what makes year two for me a little little better, at least at this point in the year.


elop a multi-year, say a three-year plan to move towards more value-based payment to providers that align value-based care with value-based payments. So the economic incentive is aligned with the care incentive like the diabetes example I provided earlier. The third area is patient engagement. What are the techniques that are used to get people more involved in their care? Simple things like open access scheduling is a great example where you can schedule your own appointments across the internet is just one example. The fourth area is population health management and there I've described in detail clinical appropriateness tools that can be used. Some of them are free, publicly available. Some you could buy later on, but just crawl, walk, run when it comes to clinical appropriateness. Start with those that are in the CMS care compare program. And then lastly, data management. Using data to really improve integrating data into the processes that are utilized. And then also developing an annual population health information technology plan that helps you move and prioritize where the data should be gathered, what your priority should be and then set up a priority setting mechanism for population health information technology. So I'm gonna summarize today. And again, this full preliminary report is posted on the website. So you can read it in detail and I hope you will. This is a great opportunity for OneCare in my opinion to be a national leader as an ACO. They have so many things that are aligned right now, being in a unique position that they are. I hope they'll take advantage of these opportunities and move to this data-driven approach to managing and to leading. And I hope they'll take a data-driven approach to transitioning healthcare in this country. It's an exciting opportunity. Change is not easy. Even the author, Machiavelli, he said, even the people who will benefit by change will resist change because people use all kinds of reasons and rationale. We want local control, you know? Does local control supersede using evidence-based care models? That's a question that needs to be addressed because sometimes people are doing things at the local level that aren't consistent with evidence-based care. And I think we owe it to the people we care for to deliver evidence-based care. So to conclude today, I think, again, you've got a great opportunity. I'm honored to participate and I hope that I can help move the needle a little bit further towards being one of the best ACOs in the country. Thank you very much. I appreciate it, Marissa. Thank you so much, Joe. Thank you so much, Joe. Let's see, we might need to turn off our... Someone needs to turn off their microphone. Getting an echo. So just a note, as Joe said, his memo is posted on the ACO oversight page. We can also put a link to that in the board meeting materials, but it's not currently with the board meeting materials. So we can get it in both places to ensure that people can see it and read. I'm gonna bring this together by presenting to you the recommendations that the staff have developed based on Joe's recommendations. So we took a look at Joe's recommendations, which are divided into those two categories, which are regulatory levers. And then he developed a set of recommendations that the ACO could use or reference also that the board could use to evaluate the ACO. But we have developed two regulatory levers, or sorry, regulatory recommendations based on his analysis and his work. So the first one, and these are new, so I'm going to read them out. They replace or enhance our former reporting requirements. So the first is that OneCare Vermont is to purchase and implement a reputable ACO benchmarking system for each payer program starting with Medicare. The selected Medicare benchmarking system should provide a payer-specific data set of peer organizations, ACOs, or integrated health systems against which to assess OneCare's performance, include identification of high-performing peer organizations and identify best practices of high-performing organizations. OneCare to select Medicare benchmarking system by February 15th, 2022. The benchmarking system must be approved by the GMCB staff prior to purchase and purchased by March 31st. These are dates that can be discussed. We're trying to figure out what operationally can actually work. This is probably the soonest that it could possibly be done based on our understanding of how the contractors work, but there's multiple issues at play. So don't read too much into the dates at this point. The Green Mountain Care Board expects to expand this requirement to Medicaid and commercial payer populations in FY23 and in spring 2022, budget update or revised budget OneCare should propose options for benchmarking systems for use in Medicaid and commercial payer programs in FY23. And the reason for starting with Medicare that I don't think we explained is that the benchmarking and data is most highly developed for Medicare. So we wanna set this up in a pilot sort of way or reporting only sort of way at first to test it. And then we have to dig a little deeper to get to the commercial and Medicaid, the proper benchmarking systems for commercial and Medicaid. Obviously we can talk more about that as we discussed its recommendation. You can go to the next slide, please Michelle. And the second one, second part of the recommendation is that the Green Mountain Care Board will issue updated reporting requirements in the ACL reporting manual pursuant to Green Mountain Care Board Rule 5.501 to implement a data-driven monitoring approach relying on payer specific national ACL benchmarking system or data sets. OneCare Vermont will report on performance and benchmarking results at least quarterly. OneCare Vermont will work with GMCD staff to finalize reporting templates by potentially June 30th with first quarterly reports. Quarter 1, 2022 due in July. And then the second part is that the FY23 ACL budget review guidance for OneCare Vermont should reflect this change in approach and introduce performance targets linked to national benchmarks along with enforcement mechanisms where OneCare Vermont does not perform at the levels outlined in the guidance. So the rule does allow the board to set benchmarks as part of our review. And this would give us the ability to do that for performance. I also want to note here that the intention is for this type of quarterly reporting to replace a lot of the sort of more ad hoc reports that we currently issue and give it a sort of more standardized high-level look. So it is intended to replace and not add to the burden of reporting that we currently have. You can go to the next and final slide please, which is just a reminder of the timeline of what's next. We have discussion period and we will come back before you as needed and for a vote. Thank you all for your time. That concludes our staff remarks. I'll turn it over to you, Mr. Chair. Thank you, Marissa. I'm going to start the board questioning with Board Member Lange-Robin. Hi, thank you. Thank you all to Joe and all of our staff. That was very thorough and comprehensive presentation. There's a lot to Q1 and to digest. I would not say that I have specific questions, but I do have some comments I wanted to throw out in terms of what I'm thinking about in terms of the recommendations for other board members to reflect on if they would like and also just for the staff to think about for next week. And I'm going to start from the most I'm going to go backwards because of my my notes. So I like the idea of moving to a more data driven approach. I think that's something that we have been trying to do in this process as it has evolved. So I'm very interested in the recommendation related to the benchmarking systems. I think that will also be very helpful in terms of moving us towards a system at the provider level that is data driven. And if there are systems out there that we can piggyback on that seems more efficient than trying to build our own, which is sort of what I think we've been trying to do. So I'm in favor of that approach and that requirement. In terms of the Medicare Advantage plans, I like the idea that one care would focus in 2022 on developing scale target programs with our local Medicare Advantage plans. I know that's been a real shift for us to see more activity in this area. So it's kind of a mixed bag. But I will say one of the pros of having a couple of local Medicare Advantage plans in terms of health care reform is that I think we may have more opportunities to work directly with those plans than with some of the national players like, for example, United or some of the other national Medicare Advantage plans that have dominated that Medicare Advantage marketplace in Vermont prior to the Blue Cross and MVP plans entering the market. So I do think this is the time is now to get ahead of that so that we can start to think about how that fits into health care reform overall. On the population health management programs, I think that as the overall one care budget for the organization or the GAP budget, as Patrick referred to it in the slides, shrinks, I think it does bring into it creates a little bit of a worry about so how do we continue to fund the population health investments as we move forward in reform. I did I generally it's disappointing I think to see those numbers go down and it's disappointing to see a movement away from primary to more community prevention efforts. On the other hand given the Mathematica analysis and what we're seeing in the quality areas and the clinical issues, I think taking a step back and really doubling down on those clinical priorities makes sense and to a point that I think just is made in prior years, we haven't really seen whether or not something like the Innovation Fund for example will actually is actually doing its job of creating best practices in state that then can be spread. So most of the reductions in that area are focused on areas I think outside of that core clinical prevention. So at least I think it the proposal that one cares brought forward is consistent with their overall focus to try and take a step back and really focus on the the clinical areas that need focus on for quality. And then I think I will end with the VBIF. So I think one of the areas that have come come up in the prior presentations around the one care budget is both the fiscal year 20 settlement as well as some of these shifts in population health investments. And I think Tom will appreciate my thinking about the settlement dollars which is these are one time dollars. And so I think under the one care policy there's a couple of options where they can distribute those back to the providers which is the deal that the providers made or reinvest them in the VBIF or other population health investments. The fact that these are one time dollars that in my mind at least seem linked to some of the strange care patterns that happened during the pandemic I would like to see some of those dollars reinvested in the VBIF and particularly for the VBIF because it is a program where there can be carry forward from year to year. And so you're not using one time dollars to invest in a program that is ongoing in which you would then need to cut the following year when you don't have this unusual shared saving situation based on strange pandemic related care patterns. So I'm interested to hear where the staff will land on the VBIF concept. I think that's a good place to focus investment and it also I think is a good place given some of the results that we've been seeing in the quality area and the Mathematica analysis. So that's kind of where I am. Overall there weren't any conditions that I was not in favor of. I think the staff did a good job of coming up with both our standard conditions that we typically have as well as thinking through kind of key areas of concern this year. Thank you Robin. Next I'm going to go to board member Pelham. Tom. One time money the bane of my existence. I want to thank the staff for an incredibly thorough presentation here. There's so much detail that you know my head is spinning and I know that I will never absorb it all. But since you're there and you have all your expertise in certain areas I feel fully fully protected from my ignorance. The I guess I'd like to start with one question that I have like one statement and a couple of short questions. The one question I had written down here before the session was in the two thousand twenty two budget data submitted. Can we see the commercial payments are scheduled at two point nine percent in FFP as contract revenue and Marissa answered that question before I got the answer. And she said no basically that you can't find it. And to me that is incredibly disappointing that that we have our largest payer out there. The commercial payer is by any any standard the largest one in Vermont in the hospital budget process of over three billion dollars in total revenues commercial payers are one point six billion of that are fifty four percent. And payment reform is one of the three core capabilities that one care has in their strategic plan. They say in their narrative that payment reform is the pivotal first step in managing overall growth in health care. And so here we are in a situation where we're trying to get married to the commercial folks and they don't seem to want to do it. We go through the hospital budget process and we find that in terms of the of NPR hospitals only comprise three tenths of one percent of hospital revenue. We saw in the chart I think it was slide sixty five that of the imbalance in terms of the public payers versus the commercial where the the public players Medicare, Medicare and the fifty one fifty four percent of their payments in in FPP and I agree some of that's the kind of loosely structured FPP but it's still FPP and the commercial of a carrier one percent. And so there's a part of me that says judge them by their actions. Maybe they don't want to participate. You know, I don't know that but I do think that that we need to come to a clear understanding with the commercial carriers, whether or not they want to you develop a working effective relationship or or decide whether or not the resources that one care is spending on on them are are being well spent. It just it just the they're they're too big a big a piece of the pie to have year after year after year not have developed a meaningful, substantive relationship with them. As we have with Medicaid, Medicaid is full FPP. They have a cost shift problem that I think we need to address. But they're they're in the end of payment reform and hopefully our efforts with Medicare, you know, over the next year, year and a half will will bear substantial fruit. And maybe that's where we should be focusing our energy on in the areas where where the relationship is is is collegial and and forward-looking. My two questions are the first one was did we get any answer back from one care about their participation in the benchmark plan review? Me, this just seems a one time opportunity, Robin, the benchmark plan, a one time opportunity to take a look at the benefits offered by Vermont's benchmark plan, which was crafted in 2013, predating all of this effort and make sure that is as as well aligned with our our goals for population health improvement and and not let this go by and even and even making sure that it's in line with our goals for popular health population health improvement before discussions, because it's going to come to us at the board at some point in time, we start talking about adding benefits to to to add to the burden of health care costs. Let's make sure that that plan is is very well structured relative relative relative to the population health. And I know maybe it's the only thing we'll find when we look at it or one care would find that it should do a brief a pre diabetes program, which we don't have in our benchmark plan. But my guess is that there is some more there. We'll probably find some high cost benefits with low cost, you know, high cost benefits of low value. So that to me is an opportunity and it's right before us now. It's not going to be here next year. And I think one care one care needs to take their talents and get engaged. And my final question had to do. With as I was at the beginning of the presentation with the the the cost of care trend developments. And I think it's a appendix four point three. It's the I would like just some explanation of these basic experience adjustments because those are they start with the twenty twenty one per member per month benchmarks. And then they insert these base experience adjustments. And I wouldn't mind if they weren't significant, but they end up substantially changing the base for the twenty for that for the twenty twenty two calculation for Medicaid traditional. It was a six point three percent increase and for Medicaid, the expanded Medicaid, it was a fourteen point seven percent increase. And so those are big numbers. And I'd just like to know kind of what what comprises a base experience adjustment. So that's it. Again, I want to applaud you all for for this. And and I agree with Robin and Robin in terms of for one time use of funds. Rarely do I get the chance to do that. So thank you. Thanks, Tom, I can take those questions. I think they're both on my sections. The first one regarding the benchmark plan, we have not received any additional information or response from one care on that beyond what they stated in at the hearing. Which I pulled up real quick that, you know, Tom Borey stated that they're happy to be a contributor in terms of learning what's more in the plan. He's looked into it a bit and has had some concerns around now that they're a 501 C3 organization being cautious around anything that looks like lobbying. And so it looks like they've there's been some thinking about it, but I don't have any more concrete response from them around their engagement with the benchmark plan. And on your second question on the trend rates, I'm going to have to punt that one to next week with Sarah Lindberg, who's going to talk about the trend developments in more detail. You know, one response. I know what Tom Bore said at the hearing.  But I bet you there's a lot of nonprofits that are engaged in this benchmark plan, including insurers, Blue Cross News Shields. So I don't unless some legal mind tells me I'm wrong, I don't accept that as an answer and and just really think that, you know, with all the data and analytics, which is one of one cares, you know, founding foundational efforts, they could be an important contributor to our benchmark plan. And they should be at the sheet. They should be at the table in my view. I don't I don't buy the nonprofit argument. Thank you, Tom. Any other comments or questions? If not, I'm going to move to to a board member Holmes, Jessica. Great. Thank you. And again, I want to echo the same huge gratitude to the staff and to Joe for all the hard work here. It's clear how much work was put into this analysis and, you know, really helpful key takeaways from each section and thoughtful recommendations. So there's a lot to digest. I have a couple of initial reactions and a couple of questions. You know, I think like some of the public comment, I'm concerned about the shrinking investment in population health programs. And again, it's not going to be a surprise. What appears to be few resources devoted to program evaluation and return on investment analysis in the in the budget. I think like the staff, I also worry about the weaker incentives in the network based risk model, coupled with smaller risk corridors, although I recognize that's a covid adjustment there and less funding for the value based incentive fund, which Robin and Tom already talked about and we heard from the staff as well. I guess essentially I'm not sure the carrots and the sticks are strong enough to incent the delivery reform that we want to see. So, you know, I understand also it's a work in progress. And, you know, some of the some of the suggestions made by Joe, I really appreciate nobody's going to be surprised to hear that I really appreciate recommendations around data driven decision making, the importance of program evaluation and the need to ensure that care delivery is appropriate and evidence based and really using some tools to analyze that. So I've thought a bit about this. I have more to think about as well, but I appreciate the approach the staff is taking. You know, a key takeaway from me is maybe we don't we aren't micromanaging line items in the budget, but we are better monitoring ACO performance and outcomes and doing, you know, a better job at holding the ACO accountable to best practices and national benchmarking standards. I think, you know, the ACO is more established now. It's more mature. And I think we need to start comparing, you know, one care Vermont to high performing ACOs across the country and requiring real accountability within the network. And so I fully endorse that condition requiring one care to purchase a Medicare benchmarking system for use in 2022 and to identify benchmarking systems for Medicaid and commercial by March of 2022 with use in 2023. I have a couple of suggestions on the recommendation on I think it's slide 41. Slide 41 is the recommendation around around the presentation on or before April 30th of 2022. One addition I would like to see to that slide is in that presentation. I'd like to hear about the proposed Medicaid and commercial benchmarks that they in the slide before it says they have to support and submit rather by the end of March. So I would like to see and hear about what those proposed benchmarks would be in their April presentation. In addition, in that April presentation, I'd like to see the ACO present a report on the results of the evaluations that they actually are doing as they described in their budget submission. One relates to care coordination and the other relates to variations in care. So if you go back to section seven of their ACO budget submission they outlined how they evaluate the care coordination model. They monitor process metrics in terms of establishment of care teams and care plans quality assurance monitoring caseloads and counter tracking and they do outcomes evaluation. ER utilization, hospital admissions, preventative care, length of stay, etc. So I would like to see the results of that evaluation presented in April. I would also like to see the results of their HSA level variations in care analysis presented in April. And in light of it's a revised budget presentation. I guess what I really want to hear is how their revised budget addresses the weaknesses that they identify in their evaluation of the care coordination model and how their revised budget addresses HSA specific variations in care that add unnecessary cost to the system and or compromise quality. I also recall at the hearing that they were pursuing a potential relationship with UVM, the academic institution, the university to explore additional evaluations. So I'd like to hear an update on that as well. So I want to make sure that in April we're hearing about the evaluations that they're doing and how their revised budgets actually incorporate the learnings from those evaluations. Like Robin, I'm also interested in the staff's recommendation around the value based incentive fund and potentially using one time money to increase that fund. Again, trying to increase those those in this case, carrots. One question I had around slide 48 was this was with respect to the benchmark trend rates in the payer contracts. I just wondered if we should include a date when those materials and conditions C2 would be due to the board. There was no date in there. There were some dates and other requirements. So I just was going to throw that out there. This is actually more a question for Joe. I really appreciated your slides. I think it was 109 and 110. You know, again, these recommendations around benchmarking and comparing one care to high performing ACOs. And I wanted to ask you how we should incorporate the information that we glean from these suggestions on the ACOs performance evaluations into our hospital budget process. And maybe this is a conversation for a later time, recognizing that we're in the interest of time here, but say that there's an HSA that seems to be underperforming on cost or quality or not applying best practices for clinical appropriateness. And this emerges in our ACO data driven performance evaluation. How should that be incorporated into our hospital budget process, if at all? So that's kind of a question that I would love to have the answer to, but maybe not at this moment in time. And then the second question around the next slide was slide, I think 112, one of the comments around provider engagement core capability. And I wondered how should one care Vermont measure meaningful provider engagement in my mind? And I think I mentioned this in the hearing. It's not enough to sign a contract. The question is if you're really engaged, are you reforming your delivery system? Are you shifting resources towards more primary prevention and the social determinants? Are the compensation contracts within that organization reflective of value, not volume? Those are the ways in which I would sort of want to measure true provider engagements. I wondered if you had suggestions for that. You want to take that, Joe? I think your first question, I think you're right, that it's going to take a more extensive discussion. And I've got some ideas, so maybe we can chat about it later on. The second question, I think your points are all very valid about measuring engagement. There are different tools we can use about patient engagement. And one of them is this basic satisfaction. There's some great CMS satisfaction measures. And the two that I find that are the most global, globally helpful. One, would you recommend this provider to other people? Yes or no? And then the second is on a scale of one to 10, how would you rate your provider? And those are two questions that I think a lot of ACOs are actually attaching incentive payments to. And that starts at the more global level. And then I think you can work down to the level of detail. But probably take a greater discussion. That's great. But actually what I was asking about was provider engagement. And I really mean true provider engagement in terms of work. We're seeing and witnessing at the provider level a change in delivery, a change in resource allocation, a change in compensation, contracting. So how does the ACO measure true provider engagement other than just participation? Yes or no? Yeah, I think number one is the fact that they really have a very high level of participation in contracting. Number one. And then number two, there are some tools you can use, some survey tools that would get to similar questions that you've identified. And so maybe talking with one care about helping them to craft a questionnaire for providers that would get to some of those questions might be a next step. Okay, that's great. Thank you. And I just have one more question for the staff, which was around. This is slide 114. Recommendations for the 2023 ACO budget guidance. And again, I think I'm going to kick this over to a future conversation, but I noticed in there there was a suggestion to incorporate both performance targets linked to national benchmarks and enforcement mechanism. So at some point in the future, I'd love to better understand what types of enforcement staff have in mind for not meeting national benchmarks. We have enforcement mechanisms in the hospital budget process, and I'm curious as to what enforcement mechanisms and thoughts the staff have on what that would look like in an ACO process. But again, in the interest of time, I'm just going to throw it out there or something to talk about at a later point. I can make a brief note about that. It's definitely longer, a bigger conversation, but that it would probably come in the form of some kind of performance improvement plans or corrective action plan or some mechanism like that. So right now we have all these ad hoc reports. Like I said, we're going to try to eliminate a lot of those in favor of this more high level reporting. But if we see underperformance in some areas, then we would require additional reporting, performance improvement plans or something like that. But we would have to sort of work that out through the pilot phase of this. Yeah, hugely helpful. Thank you. Thank you all. Thank you, Jess. I'll just touch on a few points. My colleagues have really hit most of them anyways. So I just want to say that one of the things that jumps out at me just as it did to Robin is the decrease in the population health investment. And that's an area of concern to me. I have some optimism in some of the recommendations. And I think everybody should have a goal that in a few years other ACOs in the country are benchmarking against one care of Vermont because one care of Vermont is leading the way. And so I think there's some true optimism in some of the recommendations. That doesn't mean that I'm not a little bit disappointed on some areas. And it was easy to believe very strongly that we should focus on those three key areas that were pointed out three, four years ago. But at some point I always believe that we would expand what that focus would be. And I think Joe brought up a number of potentials for best practices in a lot of different areas. And this isn't something that has to be invented. I mean, there are places like Intermountain Health and others that have protocols in place that could be copied relatively easy. And so for that reason I kind of believe strongly that Tom was really on a very important topic and that one care should be involved in the benchmark discussions, the benchmark plan. And we have to keep in mind that our goal isn't just to do things for the attributed population. It's to do certain things for the entire population of Vermont to create a healthcare system that's sustainable in the long term. And I do think that at some point in time we have to start moving to a much broader range of areas where there can be significant quality improvements and significant savings. On that same vein of thought, another concern of mine is the fact that we understood last year why the risk corridors were reduced. But if you're truly going to have providers that are invested in making the type of changes that are necessary, I think that risk corridor has to go back to where it was previously. I mean, it's just too small a risk corridor for I think somebody to take it totally serious. So that's a concern for me. Other than that, I think we've beat the other things to death. So I won't go there. But I do want to say that again, I do have optimism. That doesn't mean that I have some very big concerns. So with that, I'm going to ask before I go to the public for comment if the healthcare advocate has any comments. Thank you, Mr. Chair. I do. I should always be prepared to have a comment in case the chair just goes ahead and calls on me. Thank you. I will echo a very complete and detailed analysis. And I would offer a thank you back to your staff that my staff has been working in a good collaborative relationship. I think, well, just a few quick comments. I do work for a not-for-profit and do participate in the EHB workgroup. And but also to recognize that the EHB workgroup is considering services like hearing aids, whether adult dental could be offered in the EHB eyeglasses, et cetera. Not, that's a very different level of question than the concept of, well, just want to, that's the kind of questions that are being asked and evaluated. The other comment that I, well, the one other thing I think I'll say is just I want to admit that this is a pet peeve. I don't consume a tremendous amount of media, but when I do, I can't help but hear healthcare organization after healthcare organization advertising to me. And it's quite overwhelming, one after another, after another, entities that are regulated by you all. And since, and so I make this comment in the context of that, feeling a bit overwhelmed by it. The, I know that one care has been advised by you and by others to do a better job of telling its story. And I don't disagree with that, but one care, our care, better care, I don't think accomplishes that. And so I, and I don't know how much is being spent on, on such advertising and I don't know how it compares to public health investments or data analysis or other things that I think would be broadly supported or I would broadly support, but it is a pet peeve of mine to hear so much money being spent on name recognition. That's my comment for the moment, Mr. Chair. Thank you. You should be happy that yesterday was December 7th and we won't have to hear the Medicare Advantage ads all the time. Thank you, Mike. With that, I'm going to open it up for public comment. And if you could raise your hand through teams or if you're just on a phone, speak up and I'll recognize you. The first hand that I saw raised was Walter Carpenter. So, Walter. Wow, I'm first this time, Kevin. And the interests of Brevity, I'll try to keep this real short. I have about a thousand questions. First of all, I'm glad I'm not a board member to have to digest all of this. So, compliments to them who can do it. Second of all, I'm glad I'm not a staff member to have to put all of this together in the first place. One of the things that I noticed in that I am not a business major, not an economics major, and not a lawyer. I am a patient, activist, writer, and liberal arts man is that all of the words are most of them used in this like benchmarking, population health, data management. Exactly what do those mean? And one of the difficulties with one care on the street level is that nobody knows what all of these mean and what they're talking about, what they're trying to suggest. Like the Affordable Care Act, for instance, covered how the unaffordable care act was not affordable for most people because they always have these huge deductives. And so you see a lot of that going on. The second comment is kind of just a view from the drone of overlooking it from the drone view and seeing the whole thing is it makes me wonder, A, why Americans can take such a simple comp thing as providing health care and make it so vastly complex that a NASA engineer couldn't understand it. And how is it that an entity with a $1.36 billion budget is going to improve care and actually cut costs while improving care? And I share the concerns of Kevin Mullen that he just echoed about the population and so on. And I'll stop it there just to keep it short. Thank you, Walter. Is there other public comment? Julie Wasserman. Yes, thank you, Chairman Mullen. I have a couple comments. With regards to primary care, primary care accountability pool, wondering if someone could explain the rationale for having the struggling independent primary care physicians bear more risk than the hospital-based primary care practices that are in a much more secure situation. It looked from today's presentation that the independence are bearing 8% of total risk and the hospital-based primary care practices are bearing 7%. What slide number? Slide number 61. So which member of staff presented that slide? Mr. Chair, this is Sarah. I am happy to attempt a response at that. And now I'm also trying to find the slide. You know it's bad when you can't find your own slides because there are so many of them. Thank you very much for your question, Julie. So what we've tried to show here on the slide, and this comes from One Care's response to the round two questions, is that within the primary care accountability pool, the share of the risk paid into the pool is based on attribution. So we've included the proportion of the HSA attributed through each category. So for example, in Bennington, 31% of all Bennington attributies were attributed through non-hospital primary care, 69% were attributed through hospital-based primary care. And that is how it's broken out. So if you, you know, kind of do the math of the total primary care accountability pool amount for each HSA, you'll also have HSAs linked to the attribution numbers that One Care supplied in their round two questions response. Well, it's something that I think the Green Mountain Care Board should take a look at because we do know that our primary care physician workforce is not stable or thriving or growing or being strengthened by the ACO and to ask the independents who have borne a tremendous amount of challenges to bear more risk than the hospital base. Something about that just doesn't feel right. So that's my comment on primary care. And, you know, as Joe mentioned, this is the best ACOs, the strongest ACOs in the country are those with a robust primary care involvement. So my other comment, oh, I just want to, I do want to thank staff for making some distinction between reconciled and unreconciled payments. That's something that's a really important piece. Thank you for that. And also thank you for the 2021 scale numbers by payer program. That's also very helpful. So thank you. With regard to the ACOs quality performance, today's presentation made scant mention of the ACOs 2020 dismal performance. The ACOs performance with Medicare lives showed a worsening in half the measures. It was even worse with Medicaid nine out of 10 measures were declined from the prior year. Blue Cross Blue Shield sees no difference between ACO and non ACO lives. And as you did know, MVP scored 50 out of 100 points. So that's a pretty dismal picture. And I want to note it. And we, I think, have to take that into consideration. My specific question is, oh, where could we find Diva's final report on the 2020 results in years past? It comes out in October. And I have been unable to find it so far. Sarah, the Diva report is on our website. My understanding is that Diva does not yet have the report. But we will double check that with Diva. And if so, and if we find something different, we will get back to you. Thank you so much. Okay. Thank you. Next, I'm going to go to Dale Hackett. Interesting. You introduced the word Mathematica. The first handbook of mathematics I bought was Russian translated. And it was actually called the Handbook of Mathematica. And is now a rare book, in fact. I haven't seen that word since then. So I'm concerned about the population health and not doing more investment in that, because I also think of that as also coordination of care or that coordination of care is in that process. There's a lot I could speak to. But what I want to specifically ask is way back when they were talking about the Medicare Advantage plans. What was their take on that? I'd be really curious to know.  I got so sick of it, I called them up and they did this quick analysis to see if I was eligible. And of course I wasn't. I knew I wasn't. And then they wouldn't talk about the plans. So that had me wondering just how much value is there to these plans? They certainly put a heck of a commercial blitz on them. Well, Dale, I think many of us share your concerns about the value of the Medicare Advantage plans, but I don't think that's really the topic of discussion today. Okay. In terms of how we're doing, I'm disappointed, but I'm not surprised. I expected that with COVID and the pandemic, we've got to go down before we can come back up. I expected it to sort of tear apart the system and really challenge it. So I think it's more important what we do going forward and learn from our mistakes and or whatever you want to call them. If there aren't mistakes and just there's better policy out there, such as fee-for-service doesn't necessarily work. That's been learned or maybe people still think it does. But there's a lot to learn in here, a lot to digest. And I hope the consumer doesn't get lost in it, that we stay focused on the value statements and what actually benefits the consumer. Of course, we want the hospitals to survive and stay vibrant as well, because a vibrant hospital can serve a consumer well in terms of those quality statements and values statements. That's the end of my comment. Thanks, Dale. An important point, because a vibrant hospital is part of a patient-centric model because the patients need that care available to them. And I just want to say that today, the numbers were the worst that we've seen since the start of the pandemic. We've got really the worst situation in the last two years as far as the availability of care, especially when it comes to intensive care, because what we have in the state of Vermont today is a lot of people needing care that's not COVID related, but still needs intensive care. And to think that we have over 30 beds being taken up in ICUs with 90% of the people in those ICUs for COVID reasons being not vaccinated, it just makes me wonder where the team effort is on making sure that everybody's doing everything that they can to not just protect themselves, because I've heard people say, what difference does it make if I'm vaccinated? It does make a difference, because if we're going to get this thing under control, we need everybody's participation. And when you do get sick, you're not just hurting yourself. You're denying actually a bed to someone that may need it for another reason. And for that, I would hope that all Vermonters would start being a little bit safer and start using masks whenever appropriate, especially when going out. And the only way that this is going to get beaten back is if we all work together. And we have been a leader for the nation. And we need to get back to being a leader for the nation if we're going to be successful. Is there any other public comment on the one care budget? If not, is there any old business to come before the Green Mountain Care Board? Is there any new business to come before the Green Mountain Care Board? Is there a motion to adjourn? So moved. Second. It's been moved and seconded to adjourn. All those in favor, please signify by saying aye. Aye. Any opposed? Thank you everyone. Be safe, be healthy. And for those who won't be at our next couple of meetings, have the most joyous of holiday seasons.