My name is Kevin Mullen, chair of the Green Mountain Care Board, and I'm going to walk through the list of participants that I show on my screen that are not members of the board so that Abigail Connolly can record them for the public record. Abigail, are you all set? Yes, Kevin. Okay. So every other time I saw the whole number, now I'm just saying the beginning of the number, so let me figure this out here. So the first number with the last four digits, 4191. Devin Green from Buzz. Welcome, Devin. The next one is 2505. Jennifer Collis, TV and Medical Center. Okay. The next one is 9997, 9997. Is there an area code of 202 if that helps the person? It's Amy, but I'm on chair. Thank you. 6376. It's Mort Wasserman. Welcome, Mort. 9069. Vicki Loner, on care. Welcome, Vicki. 0043. Becky Lundafee with DRM. Welcome, Becky. 002. It's Melissa Miles with the Green Mountain Care Board. Hi, Melissa. 0193. Hey, it's Jeff Patissiste, the auditor's office. Welcome, Jeff. 5058. Susan from MVP. Welcome, Susan. Thanks, Kevin. 5835. Abigail Connolly. Oh, tricking us by using that number. Okay. 1824. Katie Jickling, Vicki Bigger. Thank you, Katie. 1-970. I believe that's the office. Yep. It's Janine. I'm at 144 state and there are no members of the public present at this time. Okay. 8267. Lucy Guerin, GRM. Welcome, Lucy. Thank you. 3212. Kathy Mahoney from the advisory council. Welcome, Kathy. 5817. Jill Guerin from BMS. Welcome, Jill. Hi. 9806. Mike Fisher, healthcare advocate. Welcome, Mike. Okay, Abigail. The next ones are actually listed by name. I have Susan Aronoff. Orca Media. Paul Ravellin. And Carol Stone. Is there anyone who I did not call off? Don Bugby here from Northwestern Medical Center. Thank you. Thank you, Julia. Sarah Berry, one care. Thank you, Sarah. Thank you. Thank you. Sarah Berry, one care. Thank you, Sarah. Are you good, Abigail? Yes. Thank you. Okay. So with that, I'm going to commence the meeting and turn it over to Susan for the executive director's report. Thank you, Mr. Chair. Good afternoon, everyone. I have really just logistic announcements for folks and scheduling announcements. Our meetings for the month of April are going to be quite fluid. We will follow all rules and the law of the open meeting law in terms of noticing these meetings. But you'll see on our website, we have our monthly press release for the month of April and the meetings after today are TBD. With that, I do want to encourage everyone to check our website under Meetings 2020. And you will see the agenda listed for those meetings when they are decided upon. We just are responding, as you can imagine, to many things at different times and need to have that flexibility. Kevin, do you have anything you want to add on that or? No. Okay. So also in terms of logistics for today's meeting and meetings going forward, all of the materials are listed on our website, again, under the meeting section and then go to 2020 meetings and you'll see the agendas as well as the slides. We're encouraging anyone presenting to make sure that they're announcing which page number they are on on the slides. I reminded Elena of that earlier, so hopefully that will make it easier to follow along. If you have any questions about where to find the materials, please reach out to Abigail Conley. And her website is abigale.conley.gov, I believe. That's right. The last thing I wanted to say was just to thank all those folks out on the front lines. We have a lot of the people on this line who are representing healthcare workers. And I just wanted to thank all of them as well as the many other people who are getting us through this crisis.  Thank you, Susan. The next item on the agenda are the minutes of Wednesday, March 25th. Is there a motion? So moved. Second. It's been moved and seconded. Mike Barber, are you on the line? I am. If you could call the roll. Member Lunge. Yes. Member Eusefer. Yes. Member Pelham. Yes. Member Holmes. Yes. Mr. Chair. Yes. Thank you. So at this point, we're going to turn it over to Alayna to talk about the fiscal year 20 ACL budget. Alayna. Great. Thank you. So Alayna Barber, director of value-based programs and ACL regulation. So you should all be able to see the presentation that I have shared. If you can't, just let me know if something happens along the way. So we are on the second page. So the goals for today are to review one carers request for operational relief that was submitted in the letter to the board on March 26th, 2020, around their 2020 budget order or in their 2020 budget order given COVID-19 and concerns around hospital solvency. So a large part of one carers budget is built on the hospital dues, approximately 26.5 million or 46% of their non-claims expenditures. So that means kind of their population health management programs as well as their administrative expense. So it's how they keep the lights on. In addition, you know, hospital costs of preparing for the pandemic are mounting and they're foregoing, you know, a lot of revenue associated with postponed and non-elective, non-urgent procedures. And the result is rapidly declining days cash on hand with negative operating margins. And I think the board has seen that through, you know, a lot of the hospital data that's been coming in recently. So if we assume, you know, 50% of net patient revenue loss, this means a corresponding loss of 115 million in operating margin each month to provide some context. And some of our hospitals have estimated upwards of 70% of revenue losses. So this is why it's really imperative that we kind of look at all of the funds flowing through the hospitals and just to make sure that, you know, we're not inhibiting our response in the state to COVID-19 with any of our previously kind of determined regulatory decisions. Okay. Slide three. So the one care request. So we're going to dive right in. So the first request was for the value-based incentive fund. The request was to waive the withhold for the Medicare portion of the fund. So this is about 0.5% of AIPDP. In their 2020 budget submitted last fall, this was an estimated amount of 8. Almost 4 million of this amount, 1.4 million, approximately 1.35 was for Medicare. So these numbers are expected to change with attribution changes, but this is as it was submitted in the fall. So it would be to waive any funds that they've collected for that provision thus far. So the rationale is that these funds could be immediately released back to the hospitals, provide financial relief during the pandemic, and the Medicare agreement does not require them to withhold this money. So the motion, if the board so chooses, and we can revisit these at the end, if you'd like, is to amend one care's 2020 budget order by reducing the total VVIS amount by the projected Medicare amount withhold of 1.351984 million, provided that one care releases any funds already withheld back to the hospitals as expeditiously as possible. So I don't know, Kevin, did you want to vote as we go, or do you want to kind of come back after we've gone through the presentation? I think we can vote as we go, but we're going to have to open it up to any public comment on any motion. Okay, great. Does the board member wish to make a motion? I can make a motion. This is Robin. I moved to amend one care's 2020 budget to reduce the total VVIS amount by the projected Medicare withhold amount of 1.351984, provided that one care releases any funds already withheld back to hospitals as soon as possible. I'll second it. So I'm going to open it up to public comment. Vicki, would you like to start it off? Kevin, thank you, and thank you for the board. This will provide some immediate cash flow to the hospitals, and we're happy to return that after this vote board makes such a motion. I just wanted to clarify that the amount is slightly less than 1.3 million with the new attribution numbers that have come in. So what would that amount be? I can send it to you at roughly one point. I think it's 1.175, but I can get you that number if it's imperative for the vote. I have it. I can pull it up if you guys are interested. Okay, but our motion, so this is Robin. The 2020 budget order, however, I think uses the 1.35 million, right? Yeah, because that's why I included that amount because it correlates to what's in the budget order. If for your information, the amount given current attribution is 1.1, like Vicki said, 1 million 109, 979. So then I don't think we need to change the motion because the motion is to amend the budget order and the 1.3 is what's in the budget order. Yeah, I agree. I think the motion is fine. I just want a clarification so that we know what exactly is going on. So with that, is there other public comment? This is Julia Shaw from HCA. Yes, Julia. HCA. Thanks. The HCA supports this motion given the current context of the COVID epidemic. Is there other public comment? This is Susan Aronoff from the Vermont Developmental Disabilities Council. And I understand the situation that we're in. I truly do. I just think that before the board votes on things, it would have been nice to put it out for public comment period. Clearly that's not being considered. Anyway, and I hope at the end of the meeting, I would like to follow up. There's some data regarding one care that should have been posted January 31st that hasn't been posted yet. So I'm asking now to have a chance at the end of the meeting to request that. Thank you. Okay. Thank you, Susan. Is there other public comment? Seeing and hearing none. Council Barber, could you call the roll? Kevin. Yes. This is Tom. I just had a question and not on the motion necessarily, but just if either Elena or can provide just a little brief, a few sentences as to the remaining $7 million under that budget item and what the revenue sources are for that. Yeah, so the remaining revenue sources are from the other payers, so Medicaid and the commercial payers. So those were not within scope of this request, but we can talk about that later in the presentation. Thank you. Any other questions from the board? If not, Council Barber. Member Holmes. Yes. Member Yousafir. Yes. Member Pelham. Yes. Member Lunge. Yes. Mr. Chair. Yes. Okay, Elena, back to you. Okay. So moving to slide four, the next request is for additional data from CMMI. So one care is requesting weekly claims data. This isn't something that we can necessarily approve or provide, but this would allow one care to more proactively monitor and adjust their Medicare fixed payments. So data is currently six weeks in a rears. We support this request and we'll discuss it with CMMI during our weekly check-ins, which our next one is scheduled for tomorrow. So we've already added it to the agenda to see how we can facilitate that need. So no vote is required there. So the next request is to extend certain deadlines required to the 2020 Budget Order. The first one to discuss is Budget Order Item 17 and 19. They'd like to move this deadline to September 30th, Budget Order 19. Originally stated that no later than April 30th, one care must provide a report on how its population health investments address cost and quality differences across health service areas as identified in one care's variation in care analysis. Number 19 had a due date of July 31st by which one care must submit to the Board of Prototype for an ACO performance dashboard. And I won't read it in detail, but this is really just about getting data submitted to the Green Mountain Care Board in a way that is like cost, quality health service area data that will allow us to kind of track and monitor how things are changing on the ground. Given staffing restrictions and one care staff that could otherwise work on this project as well as Green Mountain Care Board staff, we've kind of articulated that we think this is a good idea. So we would motion to amend the Budget Order to replace the existing dates with September 30th. And I'll pause there. If you have any questions. Are there questions from the Board? Elena, this is Robin. I think my recollection was that our original, before all of this, when we were in a normal state, we were hoping to get the guidance out around the dashboard, I think, in March or April, is that is my recollection of that correct? Yes. That's what we were shooting for. We have not been able to complete that work because of contingency planning around COVID-19 and the reduction in capacity at the Green Mountain Care Board in terms of staffing. So, you know, I think we would need some more time to complete that work in order to get one care of the guidance they needed to continue that. Great. That makes sense. I was trying to remember what our original plan was. So, thank you. Yes. So before I open it up to the public, Robin, would you like to make a motion? Sure. I moved to amend the 2020 Budget Order to revise condition 17 to change the date from July 31 with September 30, 2020. I'll second it. It's been moved and seconded. At this point, I'm going to open it up to the public for any comment. This is Julia from the HCA. Again, we also support this change. Thank you, Julia. Other public comment? Does anybody from One Care wish to make a comment on this motion? No. We just, again, thank the board for their consideration as the health care providers continue to work to deploy their efforts to COVID-19. Okay. Is there any other public comment? Is there any further board discussion? Seeing none, Council Barber, could you call the roll? Sure. Number Yusuf? Yes. Member Pelham? Yes. Member Holmes? Yes. Member Lunge? Yes. Mr. Chair? Yes. Okay, Alayna. Okay. So with that, the next request was to amend the Budget Order Language for Budget Order Item 18. This was initially requiring One Care and CBC staff to develop a work plan to evaluate the effectiveness of One Care's population health investments, including analysis of how to scale those that are successful, sunset those that are not, and report on opportunities for sustainability. One Care in their recent letter indicated that they would like to amend the language to refocus this effort around its core programs that are included in their program opinions annually. So that would kind of reduce the scope of this Budget Order Item to just include their Care Management Program and then VBIF funding, which as we've seen before is perhaps not going to be a primary focus given COVID-19. And so we actually recommend maintaining the existing language. You know, if these programs do go away, then obviously it wouldn't make sense to evaluate them. If there are any, it would be very helpful to understand how they plan to understand the impact of those programs and why it is a good investment. And I think there's enough room in this language to continue to work and figure out what the best way to demonstrate an evaluation methodology. And I think that's why we had some language in there about GMCB staff in One Care working together. With that, I will you know, I think we recommend no change, but we'll leave it up to you to discuss. So Council Barber, am I correct that no motion would be required if it remains unchanged? That's correct. Okay, is there board discussion on this issue? I'm going to open it up to the public and give One Care the first opportunity to respond. Great, thank you. I just wanted to clarify the reason why we had asked for core programs is we're trying to work with our network right now to understand which programs they themselves are able to sustain. For example, reaching out and talking to the Innovation Grant participants to see if they need to be able to hit the pause button on some of those programs, not that the funding won't continue, but the funding might be paused and then the evaluation picked up at a later date. So we wanted to have some recognition that some of these programs might need to be put on a pause approach, which will make the evaluation of their effectiveness very challenging, if not impossible for us in this current order. Okay, is there other discussion? This is Robin. To me, the original date just requires basically a work plan of the evaluation. So I think that Elaine is right, it is flexible enough to take into consideration the issues that Vicki has raised, because for example, your first item in the work plan is probably figuring out what you're going to continue and what you're going to pause. So I think that I totally hear what Vicki is saying, that it doesn't make sense to evaluate programs that may need to be put on a pause, but I think that this is flexible enough to allow for that. This is Jessica. I agree with Robin, particularly there's language in the original budget order that suggests there could be a relevant timeframe for implementation and evaluation. So if things are put on pause, then that timeframe becomes extended. This is really meant to say, we're hoping that you'll start evaluating, you know, one Kevin Vermont will start evaluating their programmatic investments in population health, develop a work plan, figure out how we're going to measure outcomes. And so I think that work can continue even if the evaluation might be paused, the language allows for that. Thank you, Jess. Anybody else from the board? Anybody else from the public? Julia from the HCA. Again, we also support the staff recommendation as Alayna presented it. Thank you, Julia. Anyone else from the public? Hearing none, we'll keep going, Alayna. Okay. So we are now on slide eight, or page eight. So the another extension of deadlines. This is for budget order items, excuse me, eight, nine and 13 from their current dates to May 30th. So this is the first budget order item. I'll just summarize. Number eight is for one care to come back and present their revised budget. This is as in previous years to come back and discuss final attribution, final payer contracts, et cetera. Number nine is, you know, correlated with eight, just suggest that they should provide their supporting documentation two weeks prior to that presentation. And budget order item number 13 is around the population health management programs, they are not fully funded. One care must submit a revised proposal. So that would kind of go along with their presentation on their revised budget. So one care provided a rationale for each of the items that we've articulated are necessary to discuss on the 15th, the way the budget order is currently written, you know, among these issues are particularly around contract negotiations that these are being updated in light of COVID-19 to address some of the concerns with, you know, how to move forward with those contracts. And then, you know, I think all the things that stem from that. So I think, you know, there is a good rationale for moving these dates. So we propose actually moving the, you know, the presentation itself to June 3rd, May 30th is a Saturday. I just moved it to the next Wednesday. And then I think it would still be helpful to, in order to provide staff time to analyze any of the documents that will be used in the presentation, you know, two weeks prior to that or two and a half weeks prior. So May 15th, that's a Friday to provide that documentation for both 9 and 13. So I'll pause there. So there would be a motion, I believe, in that order. This is Rob and I have a question. I wonder about instead of having a date certain perhaps delegating the date to either Kevin or somebody so that June 3rd to me feels pretty soon because basically if it gives a month, I think for it and contract negotiations to get reworked out which may not really be realistic. So instead of, for example, having to come back and then push out these dates again, maybe it would make sense to delegate the authority to the chair to set a date certain based on evolving circumstances. I don't know what people think about that. This is Maureen. I'll add to that as well. That was the one thing I had written down also about whether May 30th was going to be realistic to get the information that really would happen during the year, particularly for the hospital dues and the hospital risk pieces. That said, there are a couple options of ways to do it. We know that a budget is not accurate. It's something that was put forward at a point in time and that may change. Another option is to lock down on a budget date and then come back and revisit this whether it's monthly or only if it changes to give some flexibility there too. So just throwing out, you know, there's two different options rather than keeping a moving target out there, maybe aligning on a date and understanding that there may be changes to the budget as we've seen in the past as well. Other board comments or questions? This is Jessica. I would support either approach that Maureen just outlined. I have more of a question. I'm just wondering in terms of you know, this is a very volatile environment and going back and looking at the population health budget, there were some items that got some substantial increases year over year. You know, the primary prevention I think which is mostly advised from when from 707,000 up to 1.1 million. The specialist program went from 605,000 up to 3.1 million. And I'm just wondering how in this whole process whether or not those budget allocations are sacred or will folks look to be looking for savings possibly within them or redirecting those budget items. Like when this budget was done. The specialist allocation and the increase in rise or not made sense. But it might be more prudent at this point in time to redirect some of those funds generally to the area where they were directed, which is primary care and specialist care not necessarily the hospitals but to use that money to support primary care, the survival of these entities out there, many of which are as stressed as hospitals. I'm not quite sure how all this fits together but I worry that if we move something down the road to June 3rd or late May or June that these contracts are already in place and the opportunity for savings in those areas can't be had. I don't know if this is something that where one care might put the contract negotiations for these items if they haven't already been executed on hold until we get the work plan that we talked about in the last motion. Can I add something? I think there's another recommendation later in the presentation that could synthesize some of these concerns and I think we'll be asking just to provide some foreshadowing, one care to come back before this June 3rd deadline or whatever it needs to look like to talk about how their budget might be changing in order to respond to COVID-19 before that final. We just have to figure out how to have that conversation. It might require confidentiality since it is contract negotiations but I just wanted to kind of let you know that there is another opportunity that we're recommending in addition to the budget order that's separate from this that could serve as an opportunity to address those concerns. I did see that Elena. I'm just making the point that those opportunities are lost if the contracts are executed between now and that later date and I'm making that as a point that the world as we look at it right now could be different than the opportunities down the road because the contracts have been signed and the money's been committed so I'm just hoping that these contracts won't necessarily be signed until we've had a chance to kind of see the whole picture full picture again as to what might be cut and what may not be cut and where what is being cut is going to be directed. Does any board member wish to make a motion at this time? I can but I wonder if we want to talk about the Maureen's approach versus kind of whether we want to give one care a chance to respond to both options. Vicki are you prepared to respond? Kevin could you just give me a rundown of what the two potential options were that are on the table right now? I'm sure you want me to get a crack out of Kevin or you want to do it? Go ahead Maureen. I think one option is moving the date as far as when this would be acquired by from instead of making it May 30 have it more fluid between a decision between Kevin and Elena our team and your team determine when you'd have that information locked down. More the other option is it's a budget, put it together and should things change keeping us up to speed particularly on things like the hospital payments, the hospital risk as things evolve you may have more information on those things that would be different from the budget. I think it was trying to say do you feel comfortable locking into May 30 in a change or do you think you would like to extend that date? Or there could even be a hybrid motion that would allow for the extension of the dates and granting the chair the authority to extend those dates with consultation with staff and one care if necessary. So there's really like three different options that could be out there Vicki and Great. I really appreciate that flexibility. I would say right now things are very fluid and we're trying to provide as much certainty as we can and obviously trying to be responsive to the Green Mountain Care Board I think as was mentioned earlier in the conversation a lot of these contracts with payers are already locked in so this is requiring us to open back up contract negotiations as well as making some amendments and having discussions further discussions with the state as well so we would certainly appreciate the flexibility to say in May whether or not this needed to indeed be moved out a bit further to be able to give people a more concrete look into what our budget will settle out to be for this calendar year. Is there other discussion from the board? Kevin I actually like your hybrid approach where we move these dates according to the PowerPoint slide that we have in front of us but add the additional phrase that delegates authority to you to remain flexible if those dates need to be moved. Does someone wish to make that motion? Do you want to do it Jess or do you want me? I have a motion maker. I move that we revise condition 8 to change the date from April 15th to June 3rd 2020 revise condition 9 to replace the date from March 31st to May 15th 2020 and revise condition 13 to replace the March 31st date with May 15th 2020 and move that we delegate authority to Chair Mullen to further extend the deadline if needed due to COVID related issues. Second. Is there discussion from the board? I guess I'd like to ask I like this all of the three options that are out there. I would just like to ask one care, ask Vicki what contracts have not been signed. She may not know that right now but she may know it and I'm just curious as to what of these may not have been committed to contract already. I can answer that the only contract right now that really still looking to be finalized is our Blue Cross with Shield primary contract. We are hopefully inking the MVP soon so that I guess not quite signed either. Our program of payments which includes all these core programs are already committed so it will require us to change those program of payments with any of our providers to make those changes. So for example the specialist the $3.1 million in the specialist program that money is already contractually committed. Yeah so what we do is every year before we send out provider contracts we put in at what those program of payments are so the 325 payments the value based incentive fund care coordination the only exception is like the innovation funds that's more of our rolling program and I'll have to look into what exactly is in that specialist fund because the dollar amount seems high so I just need to be able to verify what's committed to that. Thank you I guess you know given that I can support the motion but if that specialist money has not been committed I would hope that those opportunities would be left open for the chair to consider this in an overall sense in an overall package so that under these trying times we're pushing the money to where it's most needed. Well and just to be clear I think the motion allows Kevin to change the dates he is not on his own deciding the budget so that'll come back to us when the date gets a bit more. No I understand that Robin I I just I'm just making the point that you know if that contrast gets signed between now and you know the end date and you know second guessing says it shouldn't have been signed the money might have been better spent somewhere else rather on a vastly expanded program that you know prudent minds kind of you know don't let that happen that full faith in the chair to you know to to execute this. So just to clarify again though the motion isn't to empower the chair to prevent any actions it's about working with the dates on this. No I understand that Kevin I just you know I just want to make the point and I understand it's just relative to the date but and I wouldn't want to hold this process up to wait for a more perfect motion so I'll support this one but I understand it's about the dates but I hope that one care is tempered in terms of executing you know future contracts until this issue is fully resolved and we know where their programs are going for the entire year. Well I think one care like the rest of the world realizes that the world changed and that we all have to think everything so is there other board comment if not I'll open it up to the public for public comment and open it first to one care if they wish to make any statement. No I think I'm all set I just want to emphasize obviously the budget's really fluid right now we're being very conscientious of where dollars are spent we're being conscientious about where dues are being held and making sure that we're providing as much relief to providers as possible during these times. Thank you very much Vicki very trying times. Other members of the public if not council barber would you like to call the roll? Member Pelham? Yes. Member Youssefer? Yes. Member Holmes? Yes. Member Lunge? Yes. Mr. Chair? Yes. Okay Alayna? Okay. We're moving to slide 11 so that brings us back to April 15th with the original deadline or the date scheduled for one care's presentation on their revised budget which we just discussed so while one care may not have the appropriate data and information to present a final revised budget by the 15th it is imperative that the board grasps how one care's budget and programs affect hospitals abilities to respond to COVID-19 and their solvency so these dues and I think we're all kind of alluding to this in our previous discussion and so the staff recommends that one care to propose an estimated revised budget even if in spirit on or before April 15th and so I think we can talk about what that is maybe it's not in quantitative terms there's a lot still fluid and in motion but we can talk about now I'm on slide 12 we can talk about what should be in that presentation we've outlined a series of questions that might be helpful to consider so how does one care see its role in the state's response to COVID-19 which of one care's programs if any are critical to hospitals and communities abilities to respond to the COVID-19 pandemic and how which programs are not critical and might be eliminated or downsized during this pandemic how is one care evaluating revisions to its 2020 budget to support the state's response to COVID-19 and in particular to support hospitals and other providers solvency including independent providers in doing so staff recommend that one care also comment on three of the budget orders items conditions excuse me number 10 12 and 16 so 10 is about the administrative expense ratio so how does we how do we expect the revised budget even if this isn't final to affect the administrative expense ratio if it's too soon to tell we can have this conversation at a later date one care has four million dollars in reserve how does one care anticipate using these funds could it be used to help engage hospitals and provide relief does one care have other value based incentive funds that could be freed up so to Tom your earlier point you know there is still a value based incentive but outside of Medicare dollars from commercial and Medicaid that that maybe there are some opportunity there but as Vicki loner has been discussing those contracts are still being negotiated so you know we understand that these things might not be final but it would be very helpful I think to the board and its regulatory authority to understand one care's budget will affect hospital hospital budgets and any to any information we can have as soon as we can have it can help us facilitate you know those processes and then the last one is how is one care leveraging the increase reimbursement for telehealth in light of COVID-19 you know so I think that would be helpful to understand in the broader picture so I think I've proposed adding in condition 22 to quantify or kind of laid these questions out to one care to come back and discuss on April 15th I think we're certainly you know open if there are other ways the board would like to take this but wanted to present it as a point of conversation so I'll pause there I'll go back to the previous slide slide 12 so you can think about it okay questions or comments from board members so this is Jessica I think I just want to lay out there that I don't think we expect a revised budget on April 15th but I think the spirit of this recommendation from the staff and the proposed motion is to really get an understanding and a check in from one care on the original date of April 15th when they were going to present sort of an update on their budget you know what is one care's role in this COVID-19 the levers that one care has to alleviate some of the financial burden on providers in the state you know how is this going to affect their budgeting process as they're evaluating revisions to it what is the process how are they prioritizing what is the criteria that they're using to think about revisions to their budget in light of the pandemic so that's the spirit of this language I believe and so I'm curious what other board members would think about this change of slide sorry just for the public slide 13 sorry Alayna to Tom's earlier point I think getting a check in on April 15th would be important so that we can understand the landscape and what people are talking about in terms of the programs and the potential changes to the budget I'm wondering if condition 22 needs to be this specific or whether it could simply be that no later than April 15th they'll present to the board on their COVID-19 response including information about potential program changes but just sort of bump it up a level so that we get an update on whatever granularity is available at that time without having to have a budget order amended because some piece of it wasn't ready other board members thank Kevin so I'm looking at the phrase here to support hospitals and other providers and I presume solvency and I presume other providers means other than includes primary the primary care folks which are the front door to the whole ACO approach and so their survivability is important and I would think that primary care providers associated with the hospital would have and there's no easy route here but an easier relatively easier route being associated with a hospital or at least most hospitals rather than being on their own and so I'm just encouraging one care you know that as we head toward this April 15th date that they reach out to the independent primary care providers in some kind of organized way so that we can get a window into their solvency issues as well so Tom as I'm reading it it says and in particular to support hospitals and other providers solvency including independent providers which I think captures who you're talking about is there something that you think is missing from that no I'm just emphasizing trying to emphasize the point of having a kind of an organized reach out to these independent providers and he'll say that when we get the view of the world from one care's perspective it's well grounded in what folks in the field are feeling out there. Okay other board comments or questions? Yeah I'm in agreement with what's been said you know I would point out April 15th is two weeks away and you know I'm not sure anyone's going to be in the position to be able to really respond to what's going to happen with COVID-19 I mean so it's this will also be fluid as far as you know what's going to what we would our expectations would be as far as I'm concerned. I agree with you Maureen but I also agree with the need to have information sooner rather than later as it relates to responses to the virus. I'm just saying you know I think the expectation is whatever is done in two weeks we're going to be figuring out as a state a lot of things as well so I think it's just going to be adjusted I'm sure during the course of the year. And I did hear Elena mention confidentiality may be required on some aspects and I'm sure that Council Barber and the legal team could work through that to we certainly don't want to get in the way of any contracts with payers or anything else so Yeah this is Mike if I could speak to that for a second I mean we have a confidentiality process for written materials that are submitted to the board but we're talking here in this proposed condition 22 about a presentation to the board and as you guys know the only way to have confidentiality in a setting like this is to go to the executive session so which is available for discussion of contracts provided you guys make certain findings about premature public disclosure of that information but that's if you guys wanted information about that that's kind of how that would have to go. Thank you Mike Other comments or questions from board members Robin do you want to take a crack on the motion? Yes Is there public comment? Yeah I was going to put the motion out first and then open it up to the public Is that okay? Sure Okay Robin I move that we add condition 22 to One Care's 2020 budget order which would read no later than April 15th 2020 One Care must prevent to the board on its role and response to COVID-19 including information available about programs program changes or potential revisions to their budget. Is there a second? Second Thank you Maureen So at this point I'm going to open it up to the public public comment This is Maureen Wasserman I think the specificity and what the staff had written in the original action which included mentioning independent providers and which member Pellum specified is critical because in fact that is an endangered large portion of primary care in this state and I can tell you from informal context that visit volumes are way down and telehealth reimbursements although they've been provided really in a heroic way are not going to make up for that and so I like the fact that in the action is originally suggested it specified that portion of the health infrastructure namely independent practice other public comment So this is Vicki if I could just give some context and comment as well I do appreciate the opportunity to have a conversation with the Green Mountain Care Board on the 15th and let them know what levers we have within our own control but obviously there are levers that have interdependencies on the payers actually agreeing to some of our recommendations I do believe that having that conversation on the 15th would be premature given where we're at with our negotiations I certainly appreciate that we as the ACO are trying to do all we can to support all of our providers including our independence and that's part of the negotiations we're trying to have right now with the payers it's also dependent on things like delivery system reform funding what's already been agreed to with the federal government in terms of where those dollars are allocated so even if we make some decisions that we don't want to go forward with some programs that's going to have to have some agreement by the federal government as well so we can certainly talk to you on the 15th of what kind of processes we're going through I don't think that we'll have definitive action on what things in our budget are going to change on the 15th also just because we don't have a board meeting until two days after the 15th so we won't even have had the opportunity to discuss this with our board and I just want to point out that our board does have two independent providers on it and we have been really working actively through them to understand what the needs are for the independent practices thank you Vicki, other members of the public hi Kevin, Mike Fisher here hi Mike so I appreciate this the spirit of this motion or this motion and the board staff's work on this as well and I think it all makes sense I think I have a more basic comment or question to pose and I want to do it carefully because I don't want to be misunderstood given the scale of what is in front of us how do we appropriately balance the all pair model effort what we've built so far and continuing with it with the tremendous need that's playing out from our communities and from our providers and with that in mind I don't know what we're going to learn from this year's demonstration year I think that and maybe more than this year's I will recognize and I think it's important to recognize I did hear UVM clearly say how important the perspective payments are at this time given what's playing out in the provider community that's noteworthy and important but I end up with a much more basic question about how to run this year and balance payments from hospitals to support one care in a more basic way given the tremendous need that the provider community is facing. Your point is spot on Mike and basically we've begun conversations with all signers to the agreement to try to figure out what is the right step forward realizing that this year is really an exogenous event and there's a clause in the contract that provides for those type of events to be considered and these are the type of things that we're working through with all signers of the agreement to try to come up with. As you said this year truly is not going to be a year that is going to give us the information that we had hoped from the all pair model and so we're going to have to make changes and we're going to have to move forward from there. And Mrs. Dickey Mike I totally agree with you that's why we're having those discussions and really need to engage the federal government in this discussion. I think the important thing as you mentioned is all of our providers that are receiving the fixed payment are saying to us that's really valuable because it's predictable and it doesn't vary based on the volume. We also have independent providers that receive that as well. So we don't want to do anything to harm them in this process. So really trying to work with the federal government to assure that predictability still continues to occur. We also have various health care reform efforts such as SASH and Blueprint that are dependent on this initiative so we just have to be very thoughtful about how we approach this year. Is there other public comment? Robin, as the maker of the motion are you satisfied that your motion takes into account the different conversations that were just had? Especially go ahead. Given that Vicki's board will not be meeting until April 17th I think it would actually be more appropriate for us to hear from them on April 22nd so that the one care board would have an opportunity to discuss the various issues and that what we hear has been flowed through that governance system. And I appreciate Mort's comments about the specificity but quite frankly if the information isn't available then what we end up needing to do is then amending the order again and again and again which just is not practical. So I too share his concern and Tom's concern about hearing about impacts across the provider spectrum including the independence and so I'm sure that we will be asking questions about that at the meeting but I personally am not comfortable with the specificity in a budget order. Robin, I hear your motion is to amend the date of your motion from April 15th to April 22nd. Is the seconder in agreement and is that a friendly? Yes. Okay. Further discussion from the board? Hearing none, Council Barber? Member Yusufer? Yes. Member Pelham? Member Pelham? Tom, if you're muted, yes. Thank you, Tom. Member Holmes? Yes. Member Lunge? Yes. Mr. Chair? Yes. Okay, Elena? Okay. Now we are on slide 14 in the last slide so next steps we just wanted to revisit this document today's board discussion and budget adjustments or budget order adjustments in a letter to one care and then we just wanted to recognize what Vicki was referencing earlier about, you know, engaging with our federal partners and I think with our other state partners where staff are continuing to review the all-pair model agreement with all of these partners to explore potential impact of the epidemic on state's performance under the all-pair model as well as to think about its effects on cash flow to providers in this time of need and we can talk about that further and more there. And that is all I have today. So thank you. Thank you, Elena. Are there any comments from the board? Hearing none. Susan, I'm not forgetting you. I don't know if you wanted to make your comment now or if you wanted to wait till after new and old business. Do you have a preference? Susan? Hi, this is Susan Ernoff. So the information that I've been looking for which that had been up January 31 and wasn't up till like the beginning of this week is now up to quarter four for ACO data as you know posted. But I guess my general comment is I hope you include some public or other stakeholders in the discussions about going forward with the all-pair model or what impact the pandemic would have on that. So some people who aren't parties to the contract could have an opportunity to have input in those decisions that impact us all. Thank you. Thank you, Susan. Is there any old business to come before the board? This is Robin.  Go ahead. So last week we approved some emergency planning statutory authority. Since that time, the legislature passed H7 42, which allows some additional flexibilities for COVID related projects. And so I wanted to raise the idea that we consider coming up with a short list of potential time-limited projects that we would specifically waive the need for CON review and approval. So the obvious examples that came to my mind were the surge sites that hospitals and nursing homes are currently planning for. I think as some people may have heard or seen in the news that CMS has just, I think it was yesterday, issued some waivers of different Medicare rules which allow for hospitals to add additional beds off-site. It would also allow nursing homes to use other essentially technically add beds by allowing for placement of patients off-site in order to make sure that they're appropriately giving people isolation for COVID related issues. So I wanted to raise that idea to see if people were open to it and if so, then I think perhaps I can work with Mike or another member of the legal team to come back next week with some guidance which we would attempt to post as soon as possible so that we can get some public comment at the Wednesday meeting. I think it's an important thing and I'm certainly open to it during times of crisis sometimes government has to get out of the way and we certainly want to make it as easy as possible as possible to create additional beds or anything else during this addressing of the pandemic. So I'm open to it. Other board members? I'm open to it as well. Yeah, this is Jessica. I agree. A good effort. You okay, Tom? I have to push my own mute button. Yes, I'm okay. Thank you. So Robin, I'll ask you to work with Mike Barber and Donna Jerry and to come forward with a proposal for the next meeting. Great and I would certainly say that if for any of our folks in the audience that if folks have concerns about that or if they have suggestions for what should be on the list that if they could please submit those and maybe we could use we always have the ability to do public comment. So I'm happy that people send it to me but it may be just easier to have it go through the usual channels which is usually I think through our public comment button or whatever. That way we can be sure that folks have an ability to chime in in the meantime. That certainly makes sense. Would it help this season? Would it help if we just did a special public comment period? Does that make sense? So people just click on it? Yes, public comment period through I don't know. What do you think Tuesday morning? Yeah, I think so and certainly like Mike and I will work together and ideally we could maybe post something before the meeting on Wednesday too depending on how much time and capacity we have to get it done. Yeah, I think this is Mike. I think it probably will require some discussion with other agencies and who are juggling a lot of things at the moment. So I'm just I think Wednesday is a good goal. But I'm just kind of worried about whether we can get a list together in time for that. But we certainly will try. Yeah, I agree. I mean, I think that the CMS guidance for that particularly for offsite facilities requires state approval which would be done through Dale in Vermont. So I think we would want to try and reach out to them to just get a sense of what if they know what their process is yet for that. But certainly since I mean in my mind if we I'm not thinking the list is necessarily going to be comprehensive so we'll keep our guidance that we approved last week so we still have a quick turnaround process. And if we have to postpone it we can postpone it knowing that we have that emergency guidance in place. But almost could be an aspirational date of next Wednesday and we'll have to go from there. Sounds good. Does any member of the public wish to comment on that proposal at this time? Hearing none, is there other old business to come before the board? Hearing none, is there any new business to come before the board? So this is Robin again. I just had a question that I wanted to pose. So since also we met last week H681 passed which made some modifications to the open meeting law that is not requiring a physical location as if we're doing an online meeting and had accessible phone numbers and things like that. And I think the other thing that caught my eye around that was that the roll call wouldn't have to be taken all the time only if there wasn't a unanimous vote. So I was just curious Mr. if you had thoughts about whether we were going to be moving in that direction now that H681 is passed. I think it's pretty likely but obviously I would want to hear from other board members before doing that. Well I think in particular for me the physical meeting location since it's Jeanine or Jean that are basically putting and we haven't had any public members coming anyway but I think if we can dispense with that especially given that we haven't had any public members that in particular to me seems desirable. Yes and I also don't believe we've had any feedback that people believe that they've lost their ability to have comment because of the Skype meeting so I think that's an important point Robin that there's no point putting anybody at risk and it would make sense to me not to have a public location but again I'd like to hear from other board members to make sure that they're in agreement. Yeah that absolutely makes sense to me as well. Yeah this is Jessica I would agree with any movement that reduces public risk reduces our staff risk absolutely. Yeah I agree as well I think it's nice for Jean and Jeanine what they've been doing but to have people not wandering but coming in and coming out of that building while it's their workspaces is probably not a good idea so I'm in agreement. Okay so that change will be made immediately and Abigail will have that up on the site so that everybody knows that they need to either call in or to log in to Skype to participate at one of these meetings and excuse me Mr. Chair Abigail did that right after H61 passed proactively but now it's reaffirmed by the board that's the direction we want to go in so that's already done. Thank you Susan. Abigail's always a step ahead of us. That's right. Okay is there other new business to come before the board? Hearing none is there a motion to adjourn? Some of Some moved. Second. Seconded to adjourn Council Barber. Member Pellin. Yes. Member Lunge. Yes. Yes. Yes. Mr. Chair. Yes. So that will conclude our meeting. Everyone be safe. Practice good social distancing. Wash your hands and the sun is shining here in Rutland. I hope it's shining wherever you are today. Have a good rest of the day.


Everybody forced to your ripping four boxes of 2020 Bowman jumbo for Jeffrey H. Thanks Jeffrey best of luck man So paper bases in ship, but we'll find the Mingas and find the Mingas paper really demingas and wit light blue Christian Javier at a 499 different different Jason B different different Jason Jason B Pain your chrome. Yeah, seriously, you're losing right now These cards are so clean Maybe it's because there's too many cards. Maybe that's what it is But McCormick Roman's coming out though. But McCormick Roman's a great amount of cards in it Jacob of Maya first moment refractor auto to 499 nice hit on the Amaya. Yo, Jeffrey Good starts They do now hidden finds of Cedric Mullins Refractor is Bryson Stott the 499 and save any autos and numbered stuff Yeah Like 30 minutes Jeffrey if you're watching at this point, you want to just see a recap Just go to the end of the video if you're watching after the fact Still be a quick recap the cards clean together makes this a long break Purple pay. Oh, no purple paper purple chrome auto to 250 is Thomas Dillard. Bobby Whit paper The Anthony's not here right now. Oh, I think Anthony's not here right now So they got the you know who in here. Yeah, can't be having any of that right now Volpe chrome. Yeah, I can't wake him up, dude Aqua shimmer is Dazz Cameron to 125 First woman auto Luis Patino speckle first bowman auto Ben Braemer to 299 and Ella Cruz Come on now Let's see some nice color 20 20. Come on needed the mangas needed the mangas Number Dominguez purple paper to 250 Marco Luciano True blue Shane Bos the 150 Check that one slow down. I was going back to work tomorrow Whit paper This is a tough box Hoping for something big here. Jeffrey got a base auto of Lenti Delgado Hoping the third auto in this one is huge Gold shimmer. Come on gold shimmer First bowman auto Jeremy Pena 47 of 50 Congrats Jeffrey There we go, man. Gorgeous paying you gold shimmer. Yeah, there we go See there. There he is Sean.  We were talking too loud 20 Gonson to 499 rookie light blue for the Dodgers It's it's never peaceful anymore. Sam gets all these people riled up and they come in here and just Like that all the time Sam is definitely an inmate trying to run the prison. That's for sure So one of the better autos to hit is Jeremy Pena Light blue Jonathan needed a 499 on the paper Yeah, Zach's chill Thank goodness Got to keep some sort of balance around here Aqua Taylor Tramble the 125 Anthony is not chill Volpe paper First woman auto is Jackson Rutledge Minga's paper We got a big card coming here another one. Let's see another one. Go causes a game hitched rick Purple Ronaldo Hernandez at a 250 Speckle first woman auto Joe Ryan at 299. It's pretty solid there Joe Ryan first woman auto Tomic inserts is to 150 Miguel Amaya If I do I'm not saying any words. I'm just gonna show it and move on I better sleep you tonight. I am feeling it now, dude We got here, uh, the first time we got here today Yeah, dude was uh Was over 14 hours ago Hey, Jordan Groeschans woman scouts top 100 autograph at a 50. All right last one coming up I'm gonna fall asleep before I hit the pillow tonight. Yeah, do me too, man. I mean like Joe Genord first woman base auto Speckle is Clark Schmidt at 299 I feel like I just drove to Chicago That was a long day too Almost as long as this day, but at least Lane didn't drive us today We're just sitting here in the safety. Yeah, I don't want to think about that man. That stuff was that was that was crazy It's like denying it too. Yeah Blue paper to 150 Joe Hotel. What was he going that fast? He says you're not paying paying attention. Yeah Lane fits right in in Florida though Oh, yeah All gas and brakes. There's no idling. There's no cruising. It's all gas all brakes.  Yeah Like you can't go that fast through those states It's like an automatic reckless like automatic. Oh, yeah Then we were legit. He did not drive a single A single tenth of a mile on the way back Not at all And we're alive today because of that rookie purple paper bobby rathley the 250 Proud I'm proud of me Can't chance it. It's all we talked about the national. It's all we talked about. Yeah He was number one of the national trash list Yeah Herki Otto's Gavin Lux He's herki Otto Gavin Lux So bowman chrome comes out next wednesday, y'all Next wednesday is bowman chrome Got those legend first bowmans feel like Roberto Clemente first bowmans in there And refractor auto louise patino to 499 and refractor is ronnie maricio to 499 recap Thanks again, jeffrey So numbered cards there was chrome stop the 499 refractor schmitt 299 Bernalda hernandez the 250 atomic megalomaya blue shane boss the 150 aqua shimmered dash camera 125 trample the 125 autos patino to 499 Gavin lux joe janord drawing groschans the 50 Jackson retledge lindsay delgado louise patino amaya to 499 speckled joe ryan to 299 a braimer to 299 Dillard to 350 and then the gold shimmer jeremy panya Appreciate it man. That's numbered 47 of 50 Get it right out to you


Okay, can I have the last slide please? So we're going to close today by talking a little bit more about the research trials that are the next generation of trials throughout the country, give you some insight, answer your questions, and then send you off to enjoy the rest of your beautiful Saturday. So when we think about kidney cancer, we think about patients at high risk for, high risk after having a resection, whoops what did I do, thank you, newly diagnosed, localized, and we think about the options for people that are in the journey of kidney cancer that we're either having to consider alternatives. So one of the things that I think is the guiding principle for you as a patient is there really is no one time that I think you've heard throughout the day when to ask your doctors about clinical trial opportunities. It can be early, it can be in the middle of treatment, it can be later depending upon how you've done, and my own view is that doctors that dismiss the opportunity to participate in a clinical trial are doctors that may have their best intentions in mind, but you have to be the best advocate for yourselves. And what I mean by that is you may have to get information, use resources, seek out a second opinion, and find out what other options are out there for you, especially as you're making transitions from one treatment to another. One of the things that we're seeing in kidney cancer today different than just three or four years ago is that many of the trials that we do prevent participation if you've had too much prior therapy. So if you've had one, two, three, four, five things, many of the trials that we and others are doing around the world and in the United States only are looking at treatments and people that have had one or two or three prior therapies. So the time point with which to ask and answer those questions for yourself is the time point when a change in treatment is being planned. And generally, when you have a change in treatment being planned, you have the time to reflect to make sure that you're doing the right thing in terms of making that decision. Rarely do you need to make a decision in 24 hours to receive therapy. So some of the things that we have here, which are just examples of what's going on around the country. So what's called the Everest trial is a trial that's in almost 1,300 patients. It's about six months from being closed. You've heard a lot about the adjuvant therapy of kidney cancer. We'll hopefully have those results this year and in the future and we'll understand whether or not treatment in patients that have undergone surgery can benefit from some of the agents that we've developed in the last decade. We are vigorously pursuing autologous personalized vaccine therapy. I happen to be the international principal investigator for this 160 institution trial. It's a trial that if positive can revisit the role that our immune system has in taking a person's own tumor to generate that immune response that we had talked about. This is a trial that's looking at the checkpoint inhibitors when compared with standard treatment. Those are phase three trials and this is a trial that when complete may offer checkpoint inhibitors for patients with previously untreated metastatic disease. This our trial is sponsored by Bristol Meyer Squibb, but there's a series of trials similarly from other companies around the country. In the second, third, and fourth line we have agents that are targeting specific new novel targets, nanoparticles that deliver drugs as you heard from Dr. Posadas in concentrations that are very, very concentrated in very small packages that hopefully get to the cancer without getting to normal tissue and then a first in human study that we're just beginning based upon science that has taken the better part of 15 years to get to the clinic. And ours is just, our program is really just representative of the kinds of kidney cancer programs around the world where people are focusing their energy and time on this disease to help you. And I just reinforced to you that I hope today was helpful, informative. You have many of the emails of the people that presented. You can ask and answer, we can ask and answer questions and hope to see you in the future. Thanks so much for taking your time out and coming today.


welcome back for another exos heroes episode in today's episode we're going to discuss the core raid but before that if you have noticed the scenery for the airship has changed okay so to my surprise this is actually very good this is actually better than what they had before so as you can see they're on top of the airship already so basically during your summoning stages you have this scene and this is actually better than the inside of the airship which is pretty much very boring so kudos to exos heroes for you know you know changing this one um i was actually i was pleasantly surprised that they changed this one so again let's go to the core raid as promised so here we are now at the core raid and the first question that you guys have been asking is is it now easier okay so let's let's let's take a look at that question and break it down into beginner and probably advanced players obviously for your advanced players it would be you know it it would become easier because number one um there's a lot of power creep in signature force and how you build your you know your team your heroes especially for the more advanced players uh the whales uh especially so basically for them it's easier but for those who are still beginning to start the game those who just started yesterday a week ago a month ago it would be harder for them so more or less this guide is more or less um going to break down the things that you that you should do and you will need to be able to succeed in every core raid that is released so right now also i noticed for this core raid they have changed the format so instead of instead of battling the new heroes they are joining you in your team so for for the hard version it's going to be real lion um to join the team with your other four heroes so i haven't actually um um gotten through core raid this is actually my free-to-play account so more or less i'd like to gauge how difficult really is core raid now versus what it was before okay and um let's move on first to the rewards okay so you have two rewards that you can you know that you can't go through so first and foremost let's go to the the the core raid pass so the core raid pass is simply accumulating experience as you as you as you're you know as you're completing the conditions for for the items below so there are six items so defeat stage one uh stage two boss stage three purchase basic items step up reward obtained and purchase raid items so these are the things that you should need in order for you to step up also in terms of going through level one to i think this is level 30 so that you could claim the final reward obviously for those who want to you know spend for the game they will they will be getting a a a fate core ticket for the core raid pass okay so that is it for the core raid pass so again even for free-to-play players they will be you know they will be able to get a lot of rewards from this and start their journey through exos heroes and our next would be your shop so more or less for the shop um what's good about the shop is as you as you play um as you play the game you'll be earning these um these are these are the tokens that you the sorry the the raid coupons that you will be getting once um you you do battle from hard this is from hard up to special and going through extreme okay so you'll be earning them through those battles and you'll be spending them here okay so more or less um you the good part about this because this is good for free-to-play as well and also for beginners so you just have to to to buy all the items to get the step up rewards which is here okay so there are five step up rewards eventually you'll be getting a a a black a a fate core recruit ticket okay so this is actually good and very you know very valuable in in the game and you'll be able to um purchase basic products up here okay so raid products down here so the main price is fate core recruit ticket so more or less this will cost you this will cost you zest in order to reset this but my point is you will be there is an opportunity that you'll be getting uh memory shards for your generals here so um memory shards are you know they come at random every time this reset so new products in 3 hours 41 minutes but again you can refresh this right now memory shards go for three and they cost 2400 raid coupons so again this is a good way of farming for memory shards for your generals and i think for this for this raid shop for this edition it would be rachel and it would be schmid for this for the generals available for the shards available for those generals okay i know this because i already you know i already finished my my my my core and i i finished today's core rate for my main account that is why i was able to get um either schmid or rachel as generals for their memory shards okay so again you'll be able to farm them here as long as you continuously play the game and as long as you have levy stones okay so let's go back to the core raid so more or less the currency for your core raid for you to play is your levy stones here so some of the players actually don't spend it anywhere they just wait for the core raid and they have spent they have saved a lot of you know a lot of levy stones already and they spend it here for this one i haven't i haven't played my my what do you call this my free to play account that much that is why it's at 4000 so we'll spend it all here um once i have a chance to play this but before that i'll show you two sources where you can add more levy stones to your to your account okay so the first source of levy stones would be on in your door to creation go to craft and you can actually convert these these are actually um earned in your in your alliance so providing friendship with alliance so you earn these hearts during your as an alliance point every day your alliances give you these and you can exchange these for levy stones as you can see so let's craft them then i'll be getting levy stones okay so another 320 then another source would be your air squadron so for your air squadron in terms of donation you can get levy stones here in terms of the normal donation so you can convert your wing tokens for for when wing token and you can get actually levy stones from here so again i got 80 so those are your two other sources of levy stones aside from your levy stones um regenerating each day or every time you stop using them they regenerate as long as they go below your maximum so the maximum is 480 for my account so it goes below 480 it regenerates and you can also purchase levy stones with zest that is also a possibility but i don't recommend this and those are the ways that you could earn levy stones or you could you know generate levy stones aside from your counter here okay we'll proceed now to gameplay okay so as for your gameplay um more or less i would what i would recommend if you are a you know if you just started the game you've been playing it for you know a month two months most of your heroes are not yet leveled up or are not you know are not powerful enough to go through hard extreme and special without breaking garden stones so because for my end for my main account i can they can already go through this without breaking garden stones but the key to surviving um core raids is having your heroes um leveled up with elemental enhancement so elemental enhancement is actually very important let let me just go back to my main heroes that some of them i'll be using later so if you can see here um reddia six ania six garfas three and aris has four and the others have none so it's actually very important that you do this in order for you to clear um the core raid and be able to clear special in the end okay so let's start with the hard so more or less my team right now is um this one so i need i need light so i have light already too light and i will be needing i will be needing um machine so for machine i'll be bringing i'll take i'll bring i think i'll bring deva because she is elementally enhanced four okay so let's go let's have a battle for this okay so as we start out now for hard um more or less the the garden stones up up our has a question mark because you don't know what the color is so let's start off with redly and deal damage so it's green the first one so as the enemy goes back from unbroken this will actually change in color so unless you you know we're able to kill the enemy or or the beast or the creature right in front of you so more or less we can let's try to to go through with this just attack it hard is actually not that hard because more or less it's easier to finish so as you can see um although i've had this you know although this is a free to play account i've had this for a while already so more or less for hard it's not really that hard and you can finish it easily okay let's now proceed to extreme so let's take a look at it's the same color actually so i'll try to bring the same team as you saw earlier with uh with hard it's pretty much easy to destroy a creature or a beast or a um a polymorph in his dungeon because you're broken him so that is actually the key to winning moderate and extreme so again let's try and break him let's try to attack him with redly see if he breaks so again the first garden stones would be would be green so again um elementally enhancing your you know your heroes actually plays a big role it's actually easier even for even for what they call this even for beginners or for or for those who have started the game um the only problem uh with elementally enhancing your heroes is you have to level up your heroes actually you have to level them up too i think it's level 90 so let's try to just attack this we are break four with still green so if it's still alive and it comes back the next garden stone will be a different color probably either it would be either lights or it would be machine so again um the key would be would be garden stone still so again um i don't think this this creature will reach will reach um its other garden stone so we'll try to clear this out so again um i think you know all in all i think this became easier but again it's it's not really for all um i i still believe that for beginners they will struggle with this okay so i had to skip out the other two battles for extreme so that i could go to special so let's try out the special difficulty with the same team that i have okay so again um to start off i think this is going to be green again if if if he's not going to be that tanky i can actually again you know kill him um with only one garden stone break so again ruddy breaks him with the first first strike so more or less i i don't see this you know this going to be to go to another garden stone so again um if you've built your account well in terms of elemental enhancing your what do you call this your your um heroes you could actually bring bring um oloom here in bathory um if you have them in your lineup to have an easier time if you don't have strong heroes or heroes with higher elemental enhance already so again this is going to be over with okay so there you go guys um just cleared it with um with my free to play account obviously i've i've i've used this account for months already that is why it's actually um advanced in terms of how i leveled up my heroes already so if you can see we we're done and let's see well let's take out let's take a look at the core rate pass so you claim this claim this rewards then you'll be able to claim rewards up there so not yet but you can actually grind this um grind your heart we you we have actually four thousand levy stones so i can actually grind this down and earn more more core rate coupons for for the core rate pass uh sorry core rate coupons for the shop so more or less i could actually spend and get these rewards the step up rewards and also if i will be able to see here um garf i'm sorry um schmidt or fc or rachel for the memory shards i can actually buy them so right now i can actually purchase already uh basic items and actually i can purchase here down below so more or less that is it guys for the core rate so um i think my opinion right now the core rate became a little bit you know a little bit more easier um so that actually it could really you know cater also to beginners beginners won't really have a hard time um going through this as long as they do a elemental enhancement or they could bring aluminum batteries so that aluminum can break multiple garden stones but more or less in general the core rate is actually easier okay guys so that is it for me so more or less those are the tips that i could give you for the core rate if you have any questions if you have any suggestions please write them down below for those who haven't subscribed yet to my channel please do around 85 percent of my viewers haven't subscribed yet okay guys thank you for staying always take care stay safe this is the warden and i'm out here