Vermont Legislature SmartTranscripts:

[Jessa Barnard (Executive Director, Vermont Medical Society)]: Eight doesn't quite line up with this two fifteen, but this is the overview of sort of where is primary care located in the state. It includes the FQHCs, the rural health centers, free and referral clinics, the VA clinics, and then hospital based primary care, independent practice, multi site and independent practice sort of one site. So, concierge or? Yes, those should be in that independent practice that probably most likely that 69 at the bottom, the smallest sort of one location independent practice. I don't have statistics on concierge practice in Vermont or direct primary care. I will say anecdotally, it is an increasing trend nationally. It's certainly an increasing trend. There's two models, somewhat similar operation, concierge practices typically do not accept insurance at all, but sort of charge a subscription. It's kind of a subscription model. You pay a set amount per year or per month to sort of belong to that practice. And then that covers the full sort of cost of care and they don't bill insurance outside of that. Direct primary care is a little different where they do bill insurance, but also charge a subscription type fee to basically have more access. And we can get to this when we're talking about panel size, see many fewer patients in their practice and typically have more longer visits or more access through text and that kind of thing after hours. But this is the total, this is all of them. This would include those practices. And then as you just heard, this is comparing to who of those practices, who are in the blueprint, that's the 124 number, 38 hospital owned, 40 independent, 46 FQHC. John and Addison gave me a lot of work explaining what a patient centered medical home is. So you've just heard all that. So that's this number of, so that's the subset of all primary care practices that are the patient centered medical home blueprint practices. I did want to highlight, and I know they just spent quite a while talking about some of the outcomes from blueprint practices. One measure I wanted to highlight, and this is a picture of the cover of their annual report, which is comprehensive and fantastic data on all sorts of outcomes and descriptions of the practices and projects of the Blueprint. I actually think we're doing, I know, and I will talk more about this, we do have access issues in primary care, but for those patients who have claims in vCures, we're doing pretty well for who has a primary care visit in a year. It's actually ninety two percent of Blueprint practices and 90% of other practices. So, in terms of those patients who have any claims in B cures, we're doing pretty well in terms of who sees their primary care practitioner that year. So who are these practitioners at the Blueprint or non Blueprint practices? I'll show you some of the data on physicians, PAs, and APRNs. The physicians data here includes MDs, NDOs. Unfortunately, this data typically has quite a lag. So right now, the latest is still 2022 physician census data, but we are seeing a decrease as you probably all know and have heard us say before in primary care practitioners. We're also seeing a decrease in the ratio of primary care to specialists. So, about twenty two percent of physicians practice primary care. An interesting thing to note here, that's five sixty nine individuals, but only four zero six FTEs. And this is my hypothesis. I haven't seen it quite yet in data. That's one of my hypotheses for why we may see smaller patient panels is more and more primary care clinicians are not practicing full time or counting

[Rep. Alyssa Black (Chair)]: as a full FTE. What is considered FTE?

[Jessa Barnard (Executive Director, Vermont Medical Society)]: That is a great question. I'd have to look at how

[Rep. Alyssa Black (Chair)]: Good question.

[Jessa Barnard (Executive Director, Vermont Medical Society)]: I'd have to go back to the census. I'm sure they define all of their measures in there. Would just have to pull that in.

[Rep. Alyssa Black (Chair)]: I consider a three day week or full time.

[Jessa Barnard (Executive Director, Vermont Medical Society)]: I'm guessing it is more than that. Can pull it up when we're done.

[Rep. Leslie Goldman (Member)]: Do hospital medicine, right? So how do you balance both parts? I'm just

[Rep. Alyssa Black (Chair)]: thinking about it like administration and charting,

[Jessa Barnard (Executive Director, Vermont Medical Society)]: I think that- Well, right, and I'll talk about that too. Yes.

[Rep. Alyssa Black (Chair)]: Three days very easily can turn into five.

[Jessa Barnard (Executive Director, Vermont Medical Society)]: Correct, I don't think this is just patient facing time. I think this is your full sort of working time, I believe, is how they're measuring it. So the ten years from when they measured this in 2022 from the ten years before, that's a 13% decline. And over the same time, specialists went up by 23%. So we've had an overall increase in physicians, but fewer primary care. Yeah,

[Rep. Alyssa Black (Chair)]: please ask. So who's hiring

[Rep. Leslie Goldman (Member)]: the specialists? Where are they hanging out?

[Rep. Alyssa Black (Chair)]: Is it all about UVM or are there more specialists embedded in this one?

[Jessa Barnard (Executive Director, Vermont Medical Society)]: It's not just UVM. I mean, didn't pull the specialist data for there, but the same, the chart, this report pulls specialist practice sites as well as primary care practice sites. And we have real needs. I don't want to diminish the need for some of the specialties we have in Vermont as well. I mean, we are really struggling things like, I I guess it's still considered specialty, general surgery, dermatology, neurology. There are real shortages of specialists as well, and there's been a real push to try to decrease backlogs and weights for some of our specialty referral practices as well. So this is not meant to be a value judgment of, did we not need those specialists? But it's more, it's just highlighting sort of the relative change between the two.

[Rep. Alyssa Black (Chair)]: We just heard from Blueprint twenty years. We've been putting resources into primary care. I mean, this is not a new problem. Our concern with primary care. Just keep going down. What are we

[Jessa Barnard (Executive Director, Vermont Medical Society)]: I agree. I guess my

[Rep. Alyssa Black (Chair)]: question is why should we do anything again, or more, or different, or Well, I

[Jessa Barnard (Executive Director, Vermont Medical Society)]: I will say one thing. Think we'd be even worse without something like the blueprint to support the work. Because one of the things we do here is, and you were asking questions about this, what are some of the, and I have some more slides, the administrative burden, quality measures, the sort of expectations of what primary care delivers is getting, is more and more. And so there needs to be a team to support that work, and there needs to be supportive payments to do that work. And we're asking, we do have high expectations of what primary care addresses. We're not just asking them to set a broken arm or prescribe some antibiotics. That's where patients do go, that is the touch point. So we want them to address mental health issues, social determinants of health. There's a lot that it gets addressed in primary care and that needs a team to support it. And I know you're gonna be hearing from more clinicians as well. I I think the practice of primary care has changed a lot, sort of what those expectations are. This is how sick the patients are, our aging population. There's a lot of compounding factors.

[Rep. Alyssa Black (Chair)]: I'm just going, have we created that environment by utilizing sort of these alternative payment mechanisms? Have we created the problem that we were trying to solve by asking them to do more? I

[Jessa Barnard (Executive Director, Vermont Medical Society)]: think the concern would be if you didn't We know it is probably unrealistic that primary care would simply get paid more and have no accountability. There is generally an understanding that if we're going to pay differently, we want to make sure that money is being put to good use and we're not because alternative payment because we've heard a lot when the ACO came into being, for example, if we're just paying you a prospective budget, how do we know you're not going to just cherry pick the healthiest patients

[Rep. Alyssa Black (Chair)]: Wait, kind of I'm going back on you. Oh, okay. You just said we would never expect to pay more and not do this. We do that literally with every other aspect of our healthcare system, except primary care. I'm sorry, I'm yelling here, I'm not yelling at you. I'm yelling at this concept. Why on earth is primary care the only one that's responsible for all of this brokenness? Don't Could we do more to

[Jessa Barnard (Executive Director, Vermont Medical Society)]: streamline and right size the quality measures and other expectations? Absolutely. Absolutely. I just I don't would anticipate What

[Rep. Alyssa Black (Chair)]: specialty has quality measures that they have to meet?

[Jessa Barnard (Executive Director, Vermont Medical Society)]: Well, with Vermont not having our ACO anymore, MIPS supplies to specialists as well as primary care. Hospitals have all sorts of quality measures they have to report to CMS. I mean, there are long term care has all sorts of gets you were talking earlier in this committee about the kind of surveys that happened in long term care. Am not advocating for more measures in primary care. Believe me, I don't want to be And

[Rep. Alyssa Black (Chair)]: I know you're not advocating for this position, but we keep hearing the same sort of theme that rolls through, which is, well, of course we should do that because we expect that and we would never question not doing that. And I'm just asking the question, why wouldn't we ever not ask the question? Because we don't ask the question of anybody else. If you're a dermatologist, you're getting rated on how many procedures you messed up or something like that or a hospital's infection borne, but you're not being measured on whether or not somebody could get a colonoscopy appointment.

[Jessa Barnard (Executive Director, Vermont Medical Society)]: I agree because no, I'm not disagreeing though. I think primary care is probably over measured for how much they're paid and we could get that better. It's just the notion that we're not going to pay you unless you do this. And we would never ask that of any other. And to add on to that, think part of the problem is the lack of consistency in the requirements from different places. It's not just one program's expectations being they may be very reasonable. But it's can we get those aligned between what the blueprint wants, what the commercial payers want, what Medicare and Medicaid want? And that was one of the goals of the ACO. It's one of the goals of the blueprint. And we very much if it were one set of agreed upon, hey, we know there's gotta be some access or quality expectations. But if they were the same pick at three, five things, that would be so much better than different measures from different places.

[Rep. Alyssa Black (Chair)]: I promise, I'm going to shut my mouth now. You can keep going.

[Jessa Barnard (Executive Director, Vermont Medical Society)]: Okay, so I'll get to so the other piece is the aging of our primary care, in particular physician workforce. I'll highlight the piece that really stands out at me. If you look back just to 2022, I'm sorry, 2002, nine percent of physicians were 60, primary care physicians. As of 2022, thirty two percent were 60. So that's a pretty dramatic jump. So we are losing, they're retiring and they are not coming in as quickly as we need. And actually, I just saw a graph this morning somewhere about the match rate. That's the new medical school graduates going into family medicine or going into their residency program, their training programs. Family medicine had the highest open spots that were not matched of any specialty.

[Rep. Alyssa Black (Chair)]: And that's bad, just so everyone knows.

[Jessa Barnard (Executive Director, Vermont Medical Society)]: Yeah, is bad. Yes. So that's the MD, DO, physician workforce. We've been trying to measure where we should want to be as a state. So this is some data that we pulled together last year comparing to some national. You can dispute whether these are exactly the right benchmarks, but it is a suggested benchmark for your primary care physician supply. And if you look back in 2016, we were about 45 FTEs short for primary care physicians, family medicine, internal medicine, OBGYN, and pediatrics. We're now up to 114 short of supply we wanna be at. And then if you compare that to some projections that the state of Vermont did a couple of years ago, it's getting a little older now, but under our SIM grant, for those who remember that, there was a whole projection of workforce needs in 2030. And if you compare where we are to where they were saying we should be in 2030, we would actually be three seventy primary care physicians in short, because demand is growing with aging demographics, more demand for primary care. Is it sticking into account

[Rep. Alyssa Black (Chair)]: sort of the team based approach, particularly with advanced practice?

[Jessa Barnard (Executive Director, Vermont Medical Society)]: Yeah, these numbers alone do not. So I will hit on, I will get to that. So this is sort of just looking at the physician alone, but then yes, what are we also seeing? So interestingly in PAs, we're seeing quite similar at least trends as physicians. So 24% of PAs practice in primary care, it was, I think 22% for physicians. So pretty similar family medicine, primary care, OBGYN, pediatrics. And similarly, in the ten years before the latest measurement, there's been a decrease in both absolute number and FTEs, whilst an increase in specialty care. Doubled. Doubled in specialty care and Where then down in primary we see the trends a little different are in the APRN workforce. So this is from the 2023 APRN census, 46% practicing in primary care, and actually an increase in primary care, but also an increase in specialty care. So about doubling of both actually from 2015 to 2023. And actually, I didn't pull the numbers. APRNs are actually, if you compare the aging of the workforce, APRNs are relatively younger than the MD and PA workforce, fewer over 60. And that is actually something that the demand modeling did cite when they're looking at how short we are, is that there has been a growth. Other primary care clinicians are helping with the shortages we're facing. So what are some of the challenges in primary care? We have these workforce challenges, too few clinicians, aging clinicians. We also have the sort of burdens we put on all of our clinicians, but a lot of it does fall or some of it falls disproportionately on primary care. This committee has spent a lot of time in the past couple of years talking about prior authorization as one example of administrative burden. These are some data we shared last year, but I know there's some new folks that are just highlighting it again. Your committee and the Senate passed a bill in 2014, Act 111, to reduce prior authorizations. And in that bill, you asked provider organizations to survey our members on their experience with prior authorizations. These were our results from about a year ago, January 2025. Clinicians report completing about 21 authorizations per week and spending fifteen hours on them. When we asked the administrators for their whole practice, the data per practice, and this was not adjusted for practice size, so just the average overall was fifty two hours of provider time and 27 FTEs of staff time spent on PAs each week in their practices. We had amazing many quotes about what the impact of prior authorization was on their staff and on their patients. One, for example, saying their practice lost three nurses in two years, mostly over the burden and frustration of dealing with prior authorization paperwork. And this is another example of how even with all the time this committee spent, as you well know, Vermont legislators and regulators can only touch so much of the health insurance spectrum. So even if we can reduce prior authorizations from our Vermont regulated plans, there are all the ERISA plans out there that are still doing different things and requiring different prior authorizations that we can never really streamline.

[Rep. Alyssa Black (Chair)]: Actually, can I ask you a question about that? Maybe you can pull your members. This is sort of an aside, because I don't think you'd be prepared to answer this. But one thing with you know, I'm always thinking about prior auths. One thing that I wasn't anticipating was I had forgotten that Medicaid, if you were in the ACO, you attributed you didn't have to do prior auths and that went away January 1. Can you survey your members or ask your members if they're having problems with that just so we can have it on our radar? Yes, and it wasn't

[Jessa Barnard (Executive Director, Vermont Medical Society)]: all prior authorizations, but there several categories where they're right. There was not, and actually part of some of what informed Act 111 was the experience of Medicaid and seeing that costs did not go up when they waived those prior authorizations or eliminated those prior authorizations altogether. And they in fact were then aligning because their experience with those providers in the ACO was so, I guess you could say net cost neutral, but yet a benefit to the providers and patients, they then got rid of it, eliminated the same prior authorizations for all providers, whether or not they were in the ACO in some instances. So yes, I'd be And we are actually tasked with this group of Along with ViState and VOS and Health First, we're surveying this upcoming fall for another report. So we could potentially even include that in it will probably affect the data, because if we're not, maybe we are seeing fewer from commercial insurers, but more from Medicaid again.

[Rep. Alyssa Black (Chair)]: That wasn't mentioned, I'm not sure how the communication around that has gone.

[Jessa Barnard (Executive Director, Vermont Medical Society)]: And then this is getting at the other, I mean, quality measures and other sort of requirements, of primary care, documentation requirements. One study was found that for every hour of direct patient time, it requires almost two hours of EHR and desk work within the clinic day. So that includes things like documenting in your medical record, the prior authorizations, the forms like workers' comp forms, school physical forms, all the kind of paperwork. And I assume this, should look, would be of the staff time, but it's also of the provider time themselves. So things like the bill you passed earlier this session around scribe technology, maybe one thing that can actually start really making a dent in these kind of burdens. Another study I find particularly interesting, again, when we're thinking of what are we asking primary care to do, what are the right things to ask primary care versus others to do. This was a little older now, but I'm sure not too different really from a 2003 study. If a a physician was to meet all of the US Preventative Task Force recommendations, the cancer screenings, hearing screening, tobacco screening, seatbelt safety, vaccination status, that would take Oh, and now it's blocking Oh, sorry. I can't see my statistic right here because my thing bar is right over. Seven point four hours per day to just do preventive screenings for your patients, not the acute care and all the other parts of the visit that need to take place. So we are asking a lot of our primary care practitioners.

[Unidentified Committee Member]: So you're just saying seven and a half hours more than actually what they're already doing?

[Jessa Barnard (Executive Director, Vermont Medical Society)]: That alone would take seven and a half hours. The conclusion being there's basically no way to actually meet all of the best practice preventive screening questions or tests with your patients who come in for your visits that day. So that would be total, I don't think that's on top. Yes, that just would for those preventive screenings. Would take seven and a half, for your number of patients who came in that day, would take seven and a half hours.

[Unidentified Committee Member]: Yeah, it excludes any additional treatment that is needed based on the assessment.

[Jessa Barnard (Executive Director, Vermont Medical Society)]: Correct.

[Rep. Alyssa Black (Chair)]: Do like that article, is there enough time for prevention? Maybe it should be, is there enough time for treatment? Right. Okay, thank you.

[Jessa Barnard (Executive Director, Vermont Medical Society)]: So all of that said, how are we doing? Shifting a little bit, so that's the provider perspective. How are we doing with patient access? Again, we will get into I'll have another slide showing based on insurance status, but overall, this is from the 2024 Vermont Behavioral Risk Factor Surveillance System report, the VRFSS. Most Vermonters actually say, identify that they have a personal healthcare provider, ninety percent. So again, that kind of matches that data about the ninety three percent going to their, having a visit. So not about ninety percent compared to eighty three percent nationally. It does vary a little bit. Side of the screen of the counties, a little bit county by county, but generally around 90%. But can they then afford to actually go for visits? Vermont, again, actually a little bit better than the national average. 8% in Vermont say they don't visit the doctor due to cost, twelve percent nationally, with again, some county, at least one county outlier. But it does vary based on insurance status, if they've actually gone and sought that care. So if you look at the second two bars, that's who received routine medical care, seventy four percent of folks with insurance, twenty five percent of those who are uninsured. So, are seeing some disparities. This is from John, at the end of his presentation, mentioned they do patient surveys. This is actually, that's the cover of their big annual patient consumer assessment. And one of the slides, or one of the questions or set of questions, is about patient access for patient centered medical homes in the Blueprint program. So can you get an appointment as soon as you needed it? When you made an appointment, did you get it as soon as you needed? And how did you get an answer? Did you get answers to your medical questions that day? So the dark blue is always, often, the green is rarely. This is showing statewide as the first FAR and then each county is after that. Again, generally actually doing pretty well, which doesn't Sometimes we hear, I'm sure you hear of challenges getting in to primary care or getting into visits. This is one though that shows a slight decrease over time. So this is showing the aggregate of all of those questions into one number. From 2020 to twenty twenty four, there is a slight decrease over time about access to primary care services, aggregating those questions that were asked. So panel size, how does this come to you? How does panel size, how many patients that's really how many patients are you could use that term attributed sort of assigned to APCP, how is that impacting access in Vermont? Interestingly, and John alluded to this a bit, it is quite hard to get to a number or a right number. We've struggled with that, sort of, can we ask our members and do a survey? But it actually, from the literature, looks like is we are not alone. And that it actually is, there is really, from what I can tell of doing some research, no established national norm, because it is so different based on patient demographics, practice demographics, practice staff model, that even some of these meta reviews pulling together lots of studies, or the VA did a big evidence synthesis when they were looking at what should their panel size be in the VA system, that there really isn't a high quality evidence supporting one right sized patient panel. And initially, I found one of the conclusions of this VA synthesis pretty interesting. Current recommendations are actually more based on historical experience than evidence. There is some evidence that increasing panel size is associated modestly with worse clinical outcomes and patient experience. But again, they really found the evidence was pretty thin. And then another deep dive into this by a California primary care project was saying that, again, it really has to be right for that practice, the sickness of those patients, and the effectiveness of the team when establishing a panel size. All that said, this I also found pretty interesting. There is some data from family physicians showing over time, panel size decreasing. Again, not necessarily a value of good or bad or a judgment on what the right size is, but from 2013 to 2022, a pretty significant and consistent decrease from about two thousand three hundred to 1,700. They had some hypotheses of why that was, is that we're actually sending less complex visits either to urgent care or our APP team members. Are there more time demands, more emphasis on value based payment and reporting, burnout, reduced hours worked, and changing position demographics. When we've asked our members, again, it's range. I did put the numbers on the bottom, but sort of big ranges from 1,200 to 2,800. And again, these are not no statistical average or median here. These were just some of the numbers we heard back. But again, one factor I do think we see in Vermont and we hear anecdotally is because of the demands of practicing primary care and all these other issues we're talking about, fewer primary care clinicians working sort of one point zero FTE. A lot of people doing 80% time, 60 time to make time for all the paperwork, the administrative burdens, the documentation, things like that, and not as many face to face patient hours.

[Unidentified Committee Member]: In any of the research, did it come up at all how the cost of care for patients might be impacting the workload for care providers? Meaning, there panels, or one of the factors, because obviously there's others, but is one of the factors also that patients just aren't able to afford to go to the doctor anymore for preventive care? They're not going and the panels are shrinking, and then when they do go, they go to the expensive

[Rep. Alyssa Black (Chair)]: care. What

[Jessa Barnard (Executive Director, Vermont Medical Society)]: I have heard, and again, I encourage you, I know you have clinicians on the calendar the next couple of days, I would encourage you to ask them. Anecdotally, what I have heard is a lot more time trying to help patients find lower cost alternatives to care. So whether it's having to prescribe another medication that's on their formulary, or which lab or imaging tests can they really afford or do they really need, or patients really trying to get the majority of their care, say, over the portal or over the phone and not coming in for a billable visit because they can't afford it or don't think they can afford it. So that's, again, adding a lot of non billable. You don't get credit for it as the provider, but a lot of time back and forth on the portal trying to adjust medications and do what really should be a face to face visit. But if the provider knows the patient's really struggling financially, they may try to work with them.

[Unidentified Committee Member]: So it sounds like I would summarize that as you do have qualitative data or anecdotal stories of how the cost of care is actually making the work harder for the primary care provider. And I guess we really wouldn't know, the primary care provider would not know how many people are not coming because they're not coming. So I'm guessing if they're seeing that much of an impact on the people who are coming, I'm wondering how many people are just not getting care, not seeking care and letting health problems linger.

[Jessa Barnard (Executive Director, Vermont Medical Society)]: Yeah, I mean, I think we can see that there is that question when it's the patient survey. This is from the Vermont Household Health Insurance Survey. This was just from 2025. If you ask patients, Are you or are you not visiting a doctor? If you do see that health care utilization is impacted by the cost of care. Patients who are uninsured are not coming in as often. And then there are other questions about, are you delaying medical care due to cost? This is from the BRFSS. On this slide, look on the slide, right under the words delay due to cost, Vermont adults do not visit doctor due to cost 2021. And then it compares based on income.

[Unidentified Committee Member]: Wow, only 8%, I would think,

[Rep. Alyssa Black (Chair)]: if this one.

[Jessa Barnard (Executive Director, Vermont Medical Society)]: Now this is 2024, so we have not seen some of the big impacts of the changes in the subsidies, and we're not yet seeing all the Medicaid coverage hit. So this could be changing. But in 2024, this was the patient answer to that question.

[Rep. Alyssa Black (Chair)]: Thanks. Not correlations, causation, but I would just, I love that chart you have that went because you know what happened right about that time? That's when Medicare mandated that you had to have an electronic health

[Unidentified Committee Member]: record. What time?

[Jessa Barnard (Executive Director, Vermont Medical Society)]: 2013. 2013.

[Unidentified Committee Member]: Oh, see, that's a good point.

[Rep. Alyssa Black (Chair)]: Then we started measuring everything. More and more and more and more and more. Easier to measure if we've got one. So, anyway.

[Jessa Barnard (Executive Director, Vermont Medical Society)]: No, well thank you, that was

[Rep. Alyssa Black (Chair)]: who knows if this, but, you know, is, I bet a little bit of that plays into it as well. For sure. I've never met a provider who loves their EMR. I don't mind mine that much. Go ahead. Leslie, and then we're going to take a short break until Jen gets her.

[Jessa Barnard (Executive Director, Vermont Medical Society)]: So I'm not sure how to think about this, so maybe you

[Rep. Leslie Goldman (Member)]: can help me. We're a small state. We have borders all over the place. Many people go outside of the state for their care. How does that get thought about? And how do we know actually what the care that population of Vermont's getting? And maybe we

[Jessa Barnard (Executive Director, Vermont Medical Society)]: So we do, well, is, and boy, there are others who would be better expert on this. It's the, and I'm forgetting which data source this is, but we do have data on the care Vermonters receive regardless of the site of care. Right? Is that in the trying to think if that would be in if it's in V Cures, it would be because of their claims are still Vermont insurer, even if they went out to Dartmouth or other locations. Okay.

[Rep. Leslie Goldman (Member)]: So people who went to Dartmouth would have it a Vermont insurer. They were a resident with a Vermont insurer, unless it

[Jessa Barnard (Executive Director, Vermont Medical Society)]: was Medicare or whatever. But then that would still be in vCures.

[Rep. Leslie Goldman (Member)]: That would still be in vCures.

[Jessa Barnard (Executive Director, Vermont Medical Society)]: Or if they went to a clinic in Massachusetts or New York, sort of across

[Rep. Alyssa Black (Chair)]: the Yeah. Yeah.

[Jessa Barnard (Executive Director, Vermont Medical Society)]: We'll need the slides, Steve. Yes, sorry. Yes, I am ready to send. I will get them for sure right over. Thank you, Jessa. Thank you very much. Thanks for letting me skip in today. Thank you to Doctor. Merman for letting me take his time. I really appreciate I sometimes

[Rep. Alyssa Black (Chair)]: feel like with people that are here all the time that I have leeway, but your time is valuable too. And I appreciate every time you're here. Okay, let's take a break until Jen gets here. I'm going to say less than ten minutes. We have two pill walkthroughs. And if we don't get through both of them, we can do one of them tomorrow because we've got some time tomorrow. We can go off of live touch.