Vermont Legislature SmartTranscripts:

[Rep. Alyssa Black (Chair)]: Good morning. Good morning. It is April 24. This is House Healthcare.

[Rep. Alyssa Black (Chair)]: Should have a pretty early day today. Done. We have a couple witnesses witnesses in. Start with Doctor Hannah Raven. We've had

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: Proxy. Proxy.

[Rep. Alyssa Black (Chair)]: That's morning.

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: Good morning. I thought

[Rep. Alyssa Black (Chair)]: we should actually get some perspective from a real primary care provider. It would be a novel thing to do. So thanks for joining us.

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: Thank you so much, Chair Black and committee. I know some of you from testifying before many years ago, Senator Cina. I'm Hannah Rabin. I'm a family doctor. I'm a Vermonter. Grew up in Marshfield. Did my training at the UVM College of Medicine, Moore College of Medicine, and residency in Burlington as well. And started practicing in 2000 at Thomas Chittenden Health Center with Rick Dooley, who I know testified here not long ago. And then in 2011, left Thomas Chittenden and started a small clinic with two other doctors in Richmond. So now I work at Richmond Family Medicine. And I will tell you a little bit about that practice because it's really dear to my heart, and it's where I go almost every day. And I think it's kind of a unique place. So I want to just give you a flavor of what that practice is like. And also, I think I was asked specifically to speak a little bit about our experience with Blueprint for Health. So I'll try to weave that in as well.

[Rep. Alyssa Black (Chair)]: I really appreciate that perspective, and I appreciate that you are going to speak to that. I will say that I've had just sort of offline conversations with various committee members, and sort of there's this overall theme of what does the blueprint even do? We don't even know the mechanism. So I'm really glad that you're here to speak to that, to maybe give a real world example of what is the blueprint and how it affects you in your practice.

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: Yeah, I'm happy to do that. And also, if something that I say is unclear or interrupted. So first, I'd like to just talk a little bit about Richmond Family Medicine and talk about what we do there day to day. We are three doctors and five primary care nurse practitioners. We have two part time psychiatric nurse practitioners who are embedded in our clinic. Through the Blueprint for Health community health team funding, we have also a community health worker who really functions like a social worker in our clinic, helping patients access services from connecting with a therapist, like Representative Cina was talking about how to refer somebody to a therapist. It's a real trick. It's a skill. And also accessing things like Meals on Wheels or figuring out what patients' needs are and how to connect them to services within the community. So that's our community health worker. We also have a referral specialist care coordinator who works with coordinating care for our patients to connect with specialists and making sure that those visits are happening and that we're getting documentation back and making sure that those patients are established there. So connecting with and the rest of also with visiting nurses and that kind of hospice services, those kinds of things. Just a clarifying question, the community health worker, is that a

[Rep. Leslie Goldman]: full time position? It is. And the Blueprint pays the entire salary?

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: How does So that half of it is Blueprint community health team money, and half of it is Blueprint expansion, which is a grant which we think will go away in June.

[Rep. Leslie Goldman]: Community health team money is Can

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: you talk about that? Yeah, so we get a certain amount of money every month to pay for very specific services. And so that is the community health worker and part of this community health worker, also this care coordinator. And a little bit of funding we also get for a nurse to do transition of care appointments with patients. So she will call a patient who's being discharged from the hospital and find out whether they're taking their medicines, make sure that we know which medicines they're taking, find out how they're doing, whether they have questions or whether they're having symptoms, and figure out a time for them to come into our clinic, typically within a week of discharge from the hospital, and make sure that they also have follow-up appointments with specialists if that's needed.

[Rep. Leslie Goldman]: Is that a per member per month?

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: It's not. That part is not per member. But that's kind

[Rep. Leslie Goldman]: of confusing, and that's why I'm confused about what someone like you gets from the loop.

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: Yeah, it's honestly confusing to us too, because there are so many different funding streams. I was actually just on the phone this morning with our practice manager saying, how much money do we actually get? Of our total revenue, how much do we actually get through Blueprint? And some of it is pass through money. So there's money from Medicare that now is coming as one time lump sums from Medicare. And Blueprint is just a pass through organization. Some of the money is per member per month from Medicaid that we get from Blueprint. And the total amount is about 7% of our total income.

[Rep. Alyssa Black (Chair)]: Social worker, nurse care management, and the other person that you said, I can't remember, are they on your payroll? They are. They are. Yes. And you just get, like for those, you get a lump sum from the blueprint.

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: Yep, and we just designate that money to go for them. So we report back to the blueprint what we're paying those people. And the blueprint has been marvelously flexible in terms of letting us figure out what our clinic needs, what do our patients need. At times, we've used Blueprint funding for nutrition classes in our waiting room at 05:15 on Thursday. Anybody on our patient panel can sign up to come to a nutrition class, a series of classes to work on healthy eating. We've had a fitness specialist who got a walking group going. And we paid that fitness specialist this was a number of years ago. The walking group keeps walking, even though the fitness specialist is not any longer part of our team. But those patients, there are like five of them just walking almost every day So we've used it for different things at different times. And one of the things that I've really appreciated about the Blueprint is that kind of flexibility to shift. And there are parameters, but we're able to help to design what works for us. So I know you have sorry to divert. So it's 7% of income. Do you have a sense of what percent of your patients are involved in your food group? I do, actually. I'm going to just get because I know exactly what we've attributed for each we do report specifically how many patients are accessing those services.

[Rep. Alyssa Black (Chair)]: I can't find it.

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: And also, we report it back by which insurance those patients have. So it's not only Medicaid patients that can access these services. Yeah, here we go. So for example, for the first actually, through the first quarter, we had 79 patients total who accessed our community health worker, two eleven patients who were working with our care coordinator, and 124 patients who our discharge planning nurse contacted after discharge from the hospital. So that's just the first quarter.

[Rep. Leslie Goldman]: Do you have a sense of what the denominator might be? I mean, out

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: of how many patients in your frack

[Rep. Leslie Goldman]: I mean, you eight providers. We have eight providers. We have almost 7,000 patients. Yeah. In your practice. So out of all of those. But not all of these are attributed blueprint patients necessarily, because what I'm understanding is that you're allowing all your patients to

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: have access to those. The blueprint is non denomination. That's right. So that's why I care about the denominator. Yeah. So I can show you that of those patients, I can tell you which insurance companies those patients were attributed to. And I can show you that. Yeah, I don't yet. Yeah.

[Rep. Alyssa Black (Chair)]: Actually, it would be helpful to know since only a few insurance companies actually pay into the blueprint. Sure. Brian Houghton.

[Rep. Lori Houghton]: Well, you said eight primary care providers, 7,000 approximate patients. And so your caseload is approximately like?

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: So it's variable. I'm going to tell you a little bit how, because it's

[Rep. Lori Houghton]: You're coming, you're going to now?

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: I'll answer your question. I have probably close to 1,200 patients who are on my panel.

[Rep. Lori Houghton]: You individually.

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: I individually have almost 1,200. And the other doctors do, too. The nurse practitioners see fewer patients on their panel. We all cross cover for each other. And one of our nurse practitioners actually was hired to cover vacations just because we're a very small team. So if I go out on vacation for a week, then my clinic days, my colleagues have to pick up extra days. And so that becomes really hard. We work eleven hour days, most of us. We're seeing patients, but also doing a lot of documentation and committee work. So it's very much a solid eleven hour day in clinic for most of us. And so it's pretty tough to take an extra day when somebody is out to come in to work. So we hired a nurse practitioner to cover our vacations. And that was one of the things that we did to try to make the practice more sustainable, to prevent burnout, which is a serious, serious problem, as I think you've probably heard from other testimony, in maintaining workforce. It's an issue.

[Rep. Leslie Goldman]: Maybe Nolan can help me with this, I'll be really but we don't have to do it now. But I'm calculating that you said 7% of income, and if I edit all those numbers right, out of 7,000 patients, it's six percent of your patients. So it sounds like it's pretty balanced. But I'll have to have help with that logic. Yeah, I don't know

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: that I would translate it exactly like that. Trying to understand impact. You want to go ahead? Sure. So I think one of the other benefits that I wanted to point to with the blueprints and with other systems that provide consistent funding streams over time is that fee for service is lumpy. It comes in fits and spurts. The first quarter of the year is dismal for fee for service, especially this year. And I have some theories about why that might be. But we always have what we call deductible season, which is when patients realize that they are starting over with their high deductibles and they try to delay care. They don't come in to be seen until typically after the first quarter. Things are starting to pick up. So we have fewer visits in the early part of the year. And our income is usually down when it's mostly fee for service. So certainly, consistent payments from a capitated system or other funding streams for quality, it really helps us to keep the lights on and make payroll and all of that. The counterpart to that is that these capitated payment programs often require a lot of administrative work in terms of doing quality improvement projects and a lot of reporting and all of that. So that's an administrative burden. And I really translate that burden into fewer patients seen. So when we think about access, think it's really important, as I know this committee has been hearing testimony about and has paid a lot of attention to the fact that reporting and these quality improvement projects can be very burdensome and take clinicians away from actually seeing patients. I wanted to speak a little bit to our history in terms of our being part of the NCQA certified patient centered medical home program. We've done that since 2013. And that was a way that we also were able to access some of this capitated funding. And then we also participated in One Care and the CPR program, which, as you know, sunsetted at the end of last year.

[Rep. Alyssa Black (Chair)]: So you were in the CPR program?

[Rep. Wendy Critchlow]: We were

[Rep. Alyssa Black (Chair)]: in the CPR program. Whatever other program, not the small per member per month, you were in the capitated.

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: We were in the capitated, bigger. So it was all of our Medicare, Medicaid and MVP payments were not fee for service, instead were thus capitated systems. So we're getting back into fee for service for pretty much everything. Now, we do have some capitation from Blue Cross Blue Shield. They have a couple of different programs, quality improvement programs. So we do get a little bit of capitated funding that way. But overall, in our first quarter, our net revenue is down 46%. So that's really substantial. I do think, having been in this game for a long time now, that this is a lot because of deductible season. And we expect our second quarter and on to be a bit better. Was that percentage different this year? Yes. That's what I'm talking about. 46% down as compared to last year. And a lot of that, I think, is that we don't have the big capitated payments from One Care. A lot of it is because I think people got shunted out of Medicaid and also because people have chosen not to pick up health insurance because it was too expensive on the exchange. And so people are not getting care. And they will. They will need it. And they will access it through the emergency room. And they will access it late. And as you know, that costs more money.

[Rep. Alyssa Black (Chair)]: I was going to ask you, under CPR, and you said that you're still under a capitated model with Blue Cross Blue Shield.

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: Just a little bit. It's like a tiny part of the Blue Cross money. Mostly we're fee for service with Blue Cross, but they do give us a small PMPM and a small quality improvement capitation.

[Rep. Alyssa Black (Chair)]: There's a part in 01/1997 that essentially tasks, I can't remember who's tasked with it, come up with sort of a methodology for the per member per month and what's included in it, what's not included in it. I think we give them a year to do it, I'm thinking, I think I could do this in one hour. But I'm just curious, under the CPR, were there services that you were receiving a fee for service for and then not receiving for other things?

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: It was kind of like a bonus. And I can't remember exactly how it was structured. But for example, a classic example is that I do skin biopsies as part of my practice. So instead of referring to a dermatologist to do a skin biopsy, if I do a skin biopsy in my office, that's covered under capitation. But why would I want to do all those skin biopsies if I can just refer all of them out and get the same capitation? So they gave us a little bonus if we did or those things were carved out. Guess that's the term, but it was carved out. I

[Rep. Alyssa Black (Chair)]: think there was a provision in here that gives them all this time to figure out what the carve outs are. I'm like, think we already You've done this.

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: It's probably been done by one care. I think another example is that we have our psychiatric nurse practitioners in our office who are seeing patients more regularly. Sometimes it's monthly visits for therapy and medication management. And so to just get capitation for those payments, we were paying our psychiatric nurse practitioners for the regular fee for service charges that they were putting in. That's how we pay them in their contracts. But then we were getting back only capitation money for any one of those patients who might be seen multiple, multiple times in a year because they really need that intensive service. So for us, it wasn't cost effective to have those patients in the capitation system only. So there was an additional carve out kind of set that for me. That's helpful. I wanted to just mention a little bit, I think, going back to giving you some idea of what it's like in the clinic, what day to day is like in our clinic. Because we're seeing patients. When I get there in the morning, I look to see who's on my schedule. I also look to see what portal messages have come in from patients overnight. I'm checking labs. I'm checking x-ray and other imaging and documents that have come in from specialists. So I'm on the computer for an hour before I actually start seeing patients. My team comes in, and we huddle, and we talk about what's happening for the day, who's there, making sure that we know who the team is. And then we start seeing patients. And as we're seeing patients, the nurses are checking patients in, doing vital signs, reconciling medications. Clinicians are going in and doing care. And we're doing everything from managing complex chronic medical disease to treating sinus infections, seeing babies and giving vaccines, and counseling patients about healthy habits and lifestyle, and doing referrals and ordering tests and prescribing medications. And all the while, phone calls are coming in and patients are asking questions. They've gotten a tick bite, and they want to know whether they can get their treatment for that. Should they be seen? And often, we're able to just the nurses are managing that according to our tick protocol, which we've ramped up again for the season because it's tick time. And so those calls are coming in. The nurses are getting portal messages from patients. We're refilling medications and doing an enormous amount of care that has nothing to do with seeing patients in the office. And yet, with the fee for service approach, the only patients that we actually revenue from through the day or for the services are the fee for service patients that are coming in through the door. So it's a funny system. And I think you all on this committee are really well aware of the fact that there's a huge amount of unpaid work in primary care. And I think that this bill is an attempt to really recognize that and to recognize that if that chronic disease family, those acute visits done in an appropriate setting, the primary care office, and the mental health services that are embedded in our primary care practices, and substance use disorder referrals or care done in primary care. If we can do all of that and get paid appropriately for all of that care, it is going to translate into much lower costs down the road. People won't be accessing care at the last minute or in the emergency room. And maybe they'll need less ICU care.

[Rep. Wendy Critchlow]: Okay, I guess I don't know for sure about this, but when we talk about the fee per member per month and primary care, we're looking like maybe you said maybe we can get a little more. Simple example of $1. How much will go primary care and how much of that other money will go elsewhere? That's my concern with that payment fee. We don't know how much it's going to be, remember. And how is that distributed? Anybody know? I know it's a study.

[Rep. Alyssa Black (Chair)]: I don't

[Rep. Wendy Critchlow]: know. We're talking about a monthly per member, per fee. We don't know how much it's going to be. And it's for primary care. Does it go into the primary care system? Does it go into blueprint for help? Where will that go? I think that's what

[Rep. Alyssa Black (Chair)]: the bill is figuring out all of those questions.

[Rep. Wendy Critchlow]: I usually like to know the answers first.

[Rep. Alyssa Black (Chair)]: You want to write it out and come up with all the answers and put it

[Rep. Wendy Critchlow]: in the No, no.

[Rep. Alyssa Black (Chair)]: We could do that, frankly.

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: I mean, I think that maybe your question has to do with what is the pass through organization that delivers it to the primary care office. So would it be Blueprint, which has some experience already with being a pass through organization? So if there's money coming from a common fund for this kind of per member, per month payment to primary care, who would administer that money, which would then, for my patients, if I have somebody in my practice who has Blue Cross Blue Shield, I would get a certain amount of money every month for just the comprehensive care for that patient, whether they get seen or not, whether they access the system or not. My clinic would get that $1 Hopefully it will be more than that.

[Rep. Wendy Critchlow]: I know. I'm trying to make it simple.

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: Right, right. So that we can keep doing what we're doing, so that we're there when she calls for care. So I guess your question is like, would administer it? Where does Just that money come

[Rep. Alyssa Black (Chair)]: because you've been talking a lot about the various things that you do and sort of the flow of your day, we had Doctor. Song in yesterday from Harvard, and he had a slide essentially of all the various types of codes that you can bill for a lot of these types of services. And he indicated how much of the utilization that primary care providers have actually like how often do they actually take advantage of the codes. So I'm wondering, because there's the new advanced practice care codes. I'm wondering if you're billing for those.

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: We are. Yeah.

[Rep. Alyssa Black (Chair)]: Are you doing like because you talked about when somebody is discharged from the hospital, are you doing like billing for the transitional care management?

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: Right, I think we only get paid by Medicare for those transition of care codes. But yes, we are billing for those. And all of that is important. And we try to stay on top of it. We don't have any professional coders on our staff. But we try our best to stay on top of it because it feels really important to keeping a clinic going, being able to pay our staff, being able to keep up with colo bases

[Rep. Leslie Goldman]: and recruitment and all of that. So how onerous is it to bill for those codes?

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: All coding and billing is onerous. I always think of primary care as being kind of like a mom and pop grocery, where somebody might come in and have 11 items that cost a tiny amount and billing for taking a wax out of somebody's ears. I mean, literally long time for that. And I bill for that when I do it, so it's time consuming. As compared to what the hospital is billed for, which is a big surgery, which is like selling a car. So mom and pop grocery versus selling a car once in a while.

[Rep. Alyssa Black (Chair)]: Any other questions?

[Rep. Lori Houghton]: What do you do when people can't afford their cost sharing and they come in and they get the service and then they're surprised with a massive deductible and they're being asked to pay their entire bill, and even though it might only be a few $100 for the primary care office?

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: Really tough, yeah. So we work with patients and we try to really individualize it. If people don't have insurance and they're paying at the time of service, we sharply, sharply reduce the amount that we ask them to pay. We have payment plans. We have some people who pay $5 a month on a very, very big ongoing bill. We certainly have forgiven large bills in the past because we knew that patients couldn't pay them and we wanted them to keep coming in to see us to get care because we knew them so well. So it's individualized. We're doctors first, probably business people second. And while we really are committed to maintaining the financial health of our clinic so that we can keep doing what we do, we really do try to individualize those situations. It's pretty heartbreaking, actually.

[Rep. Lori Houghton]: So you don't use debt collection at your practice? No. I just want to thank you immensely for that, because I haven't had a primary care provider around twenty years who hasn't taken me to debt collection when the insurance company doesn't pay something they're supposed to pay and eventually pay. You know what I mean? So it's just nice to know there's people out there who are not using that service and who are work willing with their patients on that.

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: I will tell you that we've kicked people out of the practice for not paying their bills. So sometimes that individual, mean, so maybe I'm not such an angel, I want to know. Again, it's very individualized. So I have worked with a patient who has intellectual disability for years and years and years, and she racked up a huge bill, which we just decided we're just going to let that go because it's just too important to maintain that connection. And we've got to do that. We've also had people who have been difficult. And for a number of reasons, it's been Okay to let them go.

[Rep. Lori Houghton]: But it sounds like most of the time, you try to figure out how to work with a patient. Right.

[Rep. Alyssa Black (Chair)]: And if

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: people are willing to pay $5 a month, that's just showing good intent, I think, on their part and willingness to work with us. So that's how we manage it

[Rep. Alyssa Black (Chair)]: often. Wendy?

[Rep. Wendy Critchlow]: I'm just realizing I'm a really bad patient because I'm wondering how you feel for because I hate going into the doctor,

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: I'm a one of them. No, and I'm somebody who uses the portal constantly. And how are you billing back? We don't.

[Rep. Wendy Critchlow]: I'm a really bad patient.

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: You're an invalid. I know. And now I love this bill for that reason. I mean, it's really addressing I'm grateful that you all are working so hard to try to find a solution to this problem, because we are really trying to still take care of patients. And there are newer and newer ways of being able to do that with telemedicine and phone calls for people who don't have we can't bill for phone calls. That's kind of thing. We can't bill for portal messages in a way that makes any sense. We might get $6 for a thirty minute phone call if we document it completely and put in the code. But honestly, that's not worth our time. So we don't. Thank you for pointing that out. And just as an anecdotal thing, have a friend that went in to see her doctor and she said, you know, the coding part, which I'm still trying to understand, but she said, if I ask a question about something totally unrelated, I get charged for that. It's a la carte now. Which is new, is it not? No, no, you know that. So if you ask is that like Ozempic or something? That's something That's evaluation and management.

[Rep. Alyssa Black (Chair)]: You are asking that provider to evaluate something, you manage something. It's significant and significant. Because

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: you're discussing it. I'm just This put something else on the conveyor belt at the mom and pop grocery. And we are appropriately not going to say, that's okay, you had 10 things in your cart here, and we're gonna give you this last thing. I mean, stores don't do that very often, and we can't. We just can't. Well, I'm glad that there is a mechanism that you were

[Rep. Alyssa Black (Chair)]: able to recoup some of this, but it's not enough.

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: And patients don't like it. And they come in for their wellness visit and they think that's the time that they can squeeze six problems. We have an agenda of doing their preventive care during their wellness visit, making sure that they have their vaccines and their colonoscopies and their mammograms and their bone density scans and whatever else is on the docket for that day. And then they want six problems squeezed in, which is great if we have time to do that, and often we do. But yes, we are going to build for that, because it's the only way that we can make ends meet and do what we do. Well, thank you for helping me appreciate this, and I will be a better patient.

[Rep. Wendy Critchlow]: What does that mean? I don't know yet.

[Rep. Alyssa Black (Chair)]: I want to learn from you now.

[Rep. Lori Houghton]: For me, it means not going to the doctor's field because

[Rep. Alyssa Black (Chair)]: I can't afford it. Take your time up on the portal. I'm like, why don't you go home? I'll call you this weekend and give you my 25 modifier spiel. Wendy does bring up a good point, though. So obviously, more and more people utilize portals. And I'm wondering you're wondering if you're seeing an increasing expectation of patients to actually do more things that are not reimbursed.

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: Absolutely, and patients will even say that, please answer this question, I'm not coming in because I can't pay for it, or I don't want to pay for it. I don't want available visits, just answer my question I mean, they're pretty upfront about it. And I think that there's a lot that we can manage without seeing patients. I think that that's appropriate too. I think if we can get away from this complete fee for service model, we can do care that is pretty innovative. Sometimes it's more appropriate to go to the person's house. Sometimes it's more appropriate to pick up the phone and talk to them. Sometimes we can handle urinary tract infection in a 25 year old, otherwise healthy woman over the phone. That's appropriate. We don't need to bring her in. But that's medical care, and we don't get paid for it unless she actually comes in.

[Rep. Leslie Goldman]: So you bring up the portal and thinking about your patients when they go other places and how you access that information, a workup they might have had, tests, etcetera. How does that work in your practice? Are you able to access if they go to UVM? Absolutely.

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: So do you have EPIC? We have access to EPIC. We have read only access to EPIC. So it's in there all day long. So that's great. And seeing where patients have been. I mean, there's still the problem of the EMRs being all siloed. Yes, that's what I'm looking. That's a huge, huge problem. I would love to see that change. What would be ideal for you? Everybody on the same platform? Yeah.

[Rep. Leslie Goldman]: Never mind, I've

[Rep. Alyssa Black (Chair)]: forgotten. I'm going to ask you a question which I wasn't anticipating to ask, but since you mentioned it. If you send a patient to UVM, for example, for a consultation, not a lab, not radiology or something like that, but a consultant. Do you get the consultant's note or do you have to go in and find it in Epic?

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: It's inconsistent. Sometimes we get it and sometimes we don't. And sometimes we don't know that they've gone. And that's one thing that our care coordinator is working on doing. But that's what I mean, we're in Epic all day looking for those notes. Somebody comes in and says, well, I saw my nephrologist. I'm like, oh wow, I don't see their note in your chart, and so I zipped into Epic quickly on the computer. And one

[Rep. Alyssa Black (Chair)]: of your quality measures I do know is closing the loop on a referral. So you have to go find that to get They

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: should be sending everything since we're not actually UVM clinic. They should be sending everything to us by fax, electronic fax. How much do you have

[Rep. Leslie Goldman]: to pay for having you read only access to that? That's free. Yeah, So far. Let's keep it though.

[Rep. Alyssa Black (Chair)]: You mentioned the people that you have in your office that you fund, that you pay for with the blueprint funding that Are you're any of those people working on quality measures for maintaining your blueprint payment. Yes. So we're we're we're giving you employees to get the money that you then have to pay those employees to continue getting the money.

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: Yes, they are on our quality improvement. Every year we have to recertify through the NCQA to keep our patient centered medical home status, and some of those people are on that team.

[Rep. Alyssa Black (Chair)]: I really did you have any other question? Oh, go ahead.

[Rep. Daisy Berbeco (Ranking Member)]: First of just comment. Thank you for being here. So it does seem like this fragmentation fee for service isn't like what primary care is all about. It fractures the caregiver and the patient. It'd So be great to solve that and to have you be paid for what you're actually doing, like coding for substitute phone calls or portal exchanges, and I don't

[Rep. Leslie Goldman]: know if there's a way to introduce those kinds of codes. We want to

[Rep. Daisy Berbeco (Ranking Member)]: keep the administrative burden down, but I've heard of this and I at all think it would be happening in your offices, but if you're paid, there's some kind of maybe counter incentives about, you know, how it was just described yesterday, like, you take less patients or you do less, you

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: know, there's some kind of funny Disincentive. And I which I just, I mean It's a strange dream. A little ludicrous when you think about how much unpaid work we're already doing. So it's like, we haven't been disincented so far to do the unpaid work. We're just taking care of patients. Day to day, I'm not thinking, well, does this do I get paid for this, do I get paid for that? Because work in my clinic. All the doctors, nurse practitioners, and nurses all work in one room that we call the hub. And we're there at our desks, on our computers. The nurses are answering the phones constantly, on the computers answering portal messages. We're seeing patients. It's just it's like buzzing with activity. And none of us are thinking, are we getting paid for this or that thing? We're just doing the work. We're taking care of patients. And you're welcome to come and see if that's helpful at all to see what it's like in a primary care clinic and invite you. Mean, it's just the administrative burden actually

[Rep. Daisy Berbeco (Ranking Member)]: bleeding into the fact that you can do less quality patient care because you're doing administrative stuff to be able to pay for the quality care. Chair I was just describing. So I don't know, any great solutions or insights?

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: Do have one thing that I want to say. I can just say that one concern that I have is that, maybe this gets to your question. I don't know where this money to increase the primary care portion of health care spending is going to come from. I worry that if we're shifting from fee for service to a more capitated system, that the commercial insurance will just reduce the fee for service portion. And it won't actually increase the size of the pie. If we divvy up the pie in a different way, we slice it in a different pattern, that doesn't matter. It matters a little bit because of the lumpy bumpiness of fee for service through the course of the year. So it matters a little bit. But if we don't increase the pie going to primary care, we can't do much more than we're doing. And the burden of trying to fix this health care system that isn't functioning very well, if primary care is going to help solve this problem, we actually have to fund it a little bit better. So that means increasing the size of the pie, not just slicing the dip. And Doctor. Song actually mentioned maybe you don't throw fee for service out with that. Like maybe some things are discreetly fee for service, vaccines and such, and other things more holistic I think the hybrid system could work, it's complex, and I worry about that complexity of it. But I do think that probably a hybrid system is where things might need to go. Yeah, exactly. You. Peggy?

[Rep. Wendy Critchlow]: How did One Care work with your practice, and did you see it had potential?

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: So One Care was extremely helpful for us, especially, for example, during the pandemic when we had more consistent funding. And at the beginning of the pandemic, we actually had to close the clinic for a week and just shift to all phone calls while we were getting telehealth set up, which we did within a week. It was quite quick. And we started seeing patients out in our parking lot very quickly as well. But during that transition time, we kept all our staff employed, of course, and saw a huge drop in our revenue at the beginning. And One Care really stabilized us. So it was very, very helpful in that way. So again, capitated payments, keeping a consistent funding stream. I think One Care, in terms of actually increasing our revenue, it didn't give us more than fee for service. We were a practice that was apparently pretty equivalent between the capitated payments and what they calculated in terms of shadow fee for service payments. It was about the same. It was also a small portion of our total patient population that was covered by One Care. It was Medicare, Medicaid, and MVP at the end. Blue Cross had been involved, then they dropped out. So in terms of our total revenue, it was a pretty small proportion. I think commercial insurance is definitely a bigger part of our system. Being in Chittenden County, I think it's really different in the Northeast Kingdom where they had much bigger Medicaid. So they were helpful. I have to say that my perspective on One Care was pretty jaded because it felt like we were in the trenches trying to figure out, can we squeeze out two more exam rooms from this old part of our building so that we can see more patients, hire another nurse practitioner, improve access, keep our patient panel growing a little bit. And there they were up on the hill overlooking the lake with so many lawyers and so many accountants that anytime we had a little question for them, they would have five consulting lawyers and six account ants who are on the case and coming to have a Zoom meeting with us where we saw their luxurious digs. They did have a beautiful office space where we would do with them is half supply closet and half meeting room, where some clinical staff are answering phone calls some of the day. And we're just squeezed in tight in this space. So it was a little disheartening to think like, wow, there's a middleman there using health care dollars supposedly to improve primary care and lower health care costs. But how is it that they have their fancy, mahogany lined rooms? It just didn't feel right. So that was my perspective.

[Rep. Wendy Critchlow]: Very good. Thank you.

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: That might answer Penny's question too.

[Rep. Alyssa Black (Chair)]: You've been in practice for how many years?

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: Twenty six years.

[Rep. Alyssa Black (Chair)]: Twenty six years. And so you started at Thomas Chittenden, and then you did a very frankly, because I know a lot of primary care physicians, a very brave thing and went out on your own. And you've been around practicing for twenty six years. So if you had to design what to you, like the perfect practice of medicine as a primary care physician would be, how would you design it? What would you be looking for?

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: That's a lovely question. It's so complex. I really love how we're doing it. It's small, it's grassroots. We have such an incredible team of people working together. I feel like we have such great energy. We meet together every morning in our full practice huddle because we love hanging out together and because we're ready for the day and it charges us up. So small team based, comprehensive with psych embedded and with enough money to do the things that we dream of. I would love to have our transition of care nurse go all's homes when they come out of the hospital, actually come from our office and go spend an hour with a patient going through their medicines, actually looking at the medicines and counting pills. Are you taking their pills correctly? We had a patient yesterday who said she lost half her pills in bedsheets and she couldn't figure out why she was down to nothing in her antibiotic bottle. It wasn't an opiate that she was losing. It was an antibiotic, and she couldn't figure out how she didn't have enough. So a nurse that goes in and helps to figure out, does the patient have food? So much more delving into what people's lives are really like. More therapy within the office. We've had a therapist in our office in the past, and we'd love to have that again. Nutrition services in our office, a team to help manage obesity medications, which are now a huge part of practice and very complicated to try to access those medicines for patients who really need it. It's lifesaving care, I think. So there's just some ideas. I don't have a comprehensive way to fix things. I think our clinic does an amazing job. I'm And 60 years old. I think I'm going to just keep practicing until I can't, because I love what I do. And I think that to have places where people are so integrated in the life of the clinic that they really take it on as their own, I think that's what it's going to take. And we have to be financially supported. We have to keep it going.

[Rep. Alyssa Black (Chair)]: I've been on a war against quality measures this session. Do you think that you would be less of a provider if you were not being measured? No.

[Rep. Leslie Goldman]: So what does that mean? So do you think you'd be less of a provider?

[Rep. Alyssa Black (Chair)]: Do you think you would provide less care if you weren't being measured on did you provide that care,

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: I guess? No, I think it would give us some flexibility to do the quality improvement that we've always done. We're always thinking about what do we need to do next? That's what our staff meetings are. We big paper up in our lunch room where everybody writes down suggestions. And there are little things to make the clinic feel better for patients or big things for different workflows. And we're always looking at those things to try to improve how the practice feels to work there and also the variations, of course, coming in and accessing the system without coming in. So we do quality improvement just as a matter of course. And being measured, I think, doesn't help. I understand that those that are funding want to make sure that we're using the money correctly. And yet, the way that we have to report that does feel pretty onerous. Why? Why do they need to know that?

[Rep. Alyssa Black (Chair)]: Why do they need to know that? Other specialty do we make prove they're worth? If we give them money, they must prove that they are worth that money. You're so right. That's a great perspective. I appreciate that. You're actually the second person to sit in that seat to say, I understand that they have to do this. And I just keep saying, wait a minute, why? I mean, I think we've

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: been told that for many, many years. Primary care has been accustomed to sort of doing that kind of having to prove ourselves, I think, for a long time. Can you talk about,

[Rep. Alyssa Black (Chair)]: we hear a lot about moral injuries. Do you have any thoughts on that? Do you, I don't know, are there times that you just feel, how do I keep going?

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: I mean, I think I do, in the face of what can feel like really hard work, day after day taking care of patients. I mean, there's kind of being emotionally involved in patients' lives and people have hard lives and we really see it, intimately we see it and hear what that's like And we learn how to balance it with taking care of ourselves and taking care of each other, I think in our clinic there's really a good feeling of comradery and I mean I cry when my patients die. And go to their funerals, and my staff come around and let them see that I'm having a hard day and they're right there for me, And I'm right there for them when they're going through hard things. So I think that we do have the possibility of supporting each other. But I think it's particularly hard work because we know people for years, we know people for generations. I have one family in my practice who I have four generations in my practice. And the grandmother now has dementia, And the four year old great granddaughter is just an absolute joy and one of the funniest kids I've ever met. So there's sort of this balance of life. It's such a privilege to be part of people's lives, and it's really hard.

[Rep. Alyssa Black (Chair)]: If you had to measure, and I see Leslie, if you had, we've been talking about what is meaningful, how do you measure what is meaningful?

[Rep. Leslie Goldman]: It's not measurable.

[Rep. Alyssa Black (Chair)]: Meaningful, it's not measurable. If you had to have one quality measure, one measure to indicate that you're providing quality care, what would that measure be?

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: I mean, I think I go between sort of access and patient satisfaction. Patients feeling like they have access, knowing that they can call us up and that they reach us, that they're not put on hold endlessly, they're not talking to somebody who doesn't give them the answer that they need, that they can get back to you when they get back to you. I mean, you get back to people right away, often within an hour or two. The nurses will turn around and say, I've got so and so on the phone, what do you think? Should we see them today? Or can you give them a message? And they'll say, Hannah says you should have this prescription or she's going to send it in

[Rep. Alyssa Black (Chair)]: for you. Access. And

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: I think that leads to patient satisfaction. Leslie?

[Rep. Leslie Goldman]: So I think your practice sounds amazing and the camaraderie and the way that you speak to other and sort your patients, it sounds almost too good to be true. I'm a retired family nurse practitioner, so I get it.

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: Come see us. But

[Rep. Leslie Goldman]: I'm wondering, we talk a

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: lot here about scale and how

[Rep. Leslie Goldman]: do we take what you do and able to make it more, and I'm not sure because you left a bit of a practice in order to do what you do. And so that's where I'm a little like stuck where I'm just wondering about how do we get what you are able to do in your scale in other settings, I guess, is my question.

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: I think that the other hat that I wear is that I'm chair of the board of Health First, which is the Independent Doctors Association. And we have a lot of independent practices that are doing things in ways that are innovative and that are really grassroots in the communities in Vermont. Pediatrics practices, smaller family practices, and specialty practices. And a lot of these are doing that small scale work in the little towns of Vermont. So I think supporting those independent practices and making sure that there's pay parity I mean, we typically get paid less for the same services by the commercial insurance payers and have for years. And I think you have heard about that and testified about that. I think decades can go on. So I really like that there's some pay parity and site neutral kind of language in this bill. I think that's really helpful. So that's one thing, is to already support what already exists. But how to multiply small practices and to keep that small practice feel, even when the little practice in the community is owned by the hospital.

[Rep. Leslie Goldman]: So how do we support that in this field, I guess, is where I'd like to be able to do that.

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: So pay parity. Okay, sure, that's great. Pay parity. Thank you. Any other questions? I'm sorry that Brian just left because he's so into technology. But do you see technology especially helping with the administrative burden that year? Absolutely. I use AIScribe, and it changed my life. It is incredible. And hopefully, maybe with coding and all those other things. Yeah, I think we haven't figured out how to use it to its fullest extent. But we use lots of very committed to doing evidence based practice in our clinic. And everybody has UpToDate up on their computers all day, which is a big database of medical information. We're all using open evidence and AI. So we're using technology in that way. I think the siloed EMR systems are just that's like a disaster. That's so bad. And I don't know how to remedy that. I mean, are some good things like the vaccine database now, the statewide vaccine database is really helpful for knowing who's had what vaccine. I'd like to see more of that kind of thing. Good. So I hope they can free you up to do your practice, because I'm hoping you can open it up so that you can take more patients like me, I'll be in bedwife.

[Rep. Alyssa Black (Chair)]: But you have to log in to the database.

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: Do I log into it?

[Rep. Alyssa Black (Chair)]: Yeah, you have to do a separate login to get, yes.

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: Yeah, so our nurses are doing that. I don't even know how to log into it. The nurses know how to. And so before every wellness visit, they log in and they put in a vaccine forecaster into the chart so that we this 12 old has had these vaccines and is due this time for these ones. We double check it against our system, and then we're able to administer vaccines appropriately. So that's a helpful So is this an area where the rural transformation piece of what we're doing here could be helpful to you, This is something Vital has been working on

[Rep. Alyssa Black (Chair)]: for many years, and trying to integrate their information into individual electronic health records because there are many of them. May I ask what health record you use?

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: Yeah, have NetEnt, which is small and user friendly for primary care. Thomas Jinden also uses Medenden. This is our third EMR. Oh, yeah, so that becomes worth a marsupine career and brutal to awful.

[Rep. Alyssa Black (Chair)]: You. Could you point me to

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: the pay parity section that you can go to?

[Rep. Alyssa Black (Chair)]: I don't think there really is a pay parity section in here, there's more of a

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: net financial

[Rep. Alyssa Black (Chair)]: in developing

[Rep. Leslie Goldman]: And where is that?

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: Section six.

[Rep. Alyssa Black (Chair)]: I haven't refreshed myself on the bill.

[Rep. Leslie Goldman]: That's why I just want to

[Rep. Alyssa Black (Chair)]: not lose it. Oh, here we go. Thank you, Doctor.

[Rep. Wendy Critchlow]: Rabin. Thank you.

[Rep. Alyssa Black (Chair)]: I really appreciate it. Thank

[Rep. Daisy Berbeco (Ranking Member)]: you very much.

[Rep. Alyssa Black (Chair)]: And we have Susan. Susan. Hi, How are you?

[Susan Ridzon (Executive Director, Vermont Health First)]: Sorry I'm not there in person. I'm sparing you my cold germs. But that was a great discussion. Thank you, Doctor. Rabin. I think she really demonstrated the value of primary care, particularly independent primary care, so that was really great. So, can everybody hear me okay? Yep. For the record, my name is Susan Ritson. I'm the executive director of Vermont Health First, which is the Independent Practice Association that, doctor Rabin referred to. And, I know many of you have heard this already, but for those of you who haven't, we represent about 68 clinician owned primary care and specialty care practices across Vermont. So there's that. And my understanding is that, Chair Black, you wanted to get a sense of why a practice might not participate in BLUEPRINT, is that correct?

[Rep. Alyssa Black (Chair)]: Yes, I had kind of put feelers out to say, let's get somebody in here who doesn't participate, but we couldn't find anyone because they don't participate and we don't know

[Susan Ridzon (Executive Director, Vermont Health First)]: Yes, I did try, but Busy I patient schedules. Thank you for trying. But I was able to get some feedback on some of the reasons, and I'll just say first that the large majority of our primary care practices are blueprint participants. There's only a few that do not participate, and they tend to fall into they have, you know, pretty similar characteristics. That is they're very small practices, usually one or two providers. And they generally, if they've looked at whether or not to participate in the Blueprint, they've determined that the per member per month payments, just don't aren't enough or they don't have enough attributed patients because they're smaller practices for that per member per month payment to cover the cost of the patient center medical home certification and the other administrative, you know, reporting and things that are associated with the blueprint program. So that's the primary reason. I also have heard from a couple of them that, you know, doctor Raven talked about the community health team. And I I know that, our practices who do participate in the Blueprint find that very valuable. And there at Richmond Family Medicine, they do have embedded clinicians. But when you're a really small practice, you're usually sharing that clinician, and some of the practices think, well, I don't, you know, I don't have enough patient need for this. You know, I I'm not really gonna get the value out of it. Although I think I'm not sure they fully understand that they could share that with another practice, but overall, they deem that it's just too administratively complex for them to, you know, make their margins and participate. The other thing I'll mention, believe it or not, we actually have two practices in our network who do not use an electronic health record, and that's a deliberate choice, because, you know, EHRs are expensive and come with admin burden, and these practices have chosen to keep it, you know, simple. And the blueprint does require that you have an EHR. They didn't use to, and I I think it's actually more related to the patient center medical home certification requirements needing an EHR, but that automatically disqualifies someone from participating. So what you know, one thing that would be nice is just to, if the blueprint is really aiming to support all primary care, to, you know, gear it more toward small practices so that they're able to benefit just as much as a larger practice would. And, you know, I think that would result in less administrative burden and and better, you know, PMPM payments, basically.

[Rep. Alyssa Black (Chair)]: I'm wondering if, from your perspective in representing, there's sort of this, and it's in rural health transformation as well, of moving primary care sort of out of our hospital based system. And I'm wondering if you have thoughts about, since you represent more of the independent practices, if you have thoughts around whether or not the blueprint might actually drive or even Doctor. Rabin, if she'd like to weigh in on this, if the administration of the Blueprint, that there are providers who just say, There's just too much. I want somebody else to handle it. Do you think that's one of the reasons why we see a lot of people going into sort of more hospital based where the administration is who can actually do these things, if that is kind of eroding independent practice?

[Susan Ridzon (Executive Director, Vermont Health First)]: I I don't know if Doctor. Rabin wants to chime in, but I would say absolutely administrative burden is a huge problem, particularly for independent practices who just don't have the personnel and margins, frankly, to just absorb that.

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: Yeah, I think that that was actually something that came out in that 2015 study that the Green Mountain Care Board did, looking at why, I think it was a job satisfaction and dissatisfaction. And I think that for independents who moved into hospital based, it was really because they were dissatisfied with the administrative burden of running a graph. So, I mean, you're kind of virtually a business person and administrator. I mean, we are our own kind of CEOs and CFOs and we sweep the parking lot too.

[Rep. Alyssa Black (Chair)]: So,

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: I think it's administrative burden and just the burden of running a practice. Yes, the blueprint which requires a certain amount of reporting and being in CQA certifying requires a body of reporting, of documentation.

[Rep. Alyssa Black (Chair)]: And also trying to think, we talked about making sure that you bill for every single little thing. Any more thoughts, Susan? Anyone have any questions?

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: Right.

[Rep. Alyssa Black (Chair)]: Well, We keep

[Susan Ridzon (Executive Director, Vermont Health First)]: the committee's focus on this. Thank you.

[Rep. Alyssa Black (Chair)]: K. I will put it out there. I've also been trying to find a concierge position, but I cannot

[Susan Ridzon (Executive Director, Vermont Health First)]: find someone. Oh, you do? Sorry to interrupt. Yep. She's not available till later next week. But

[Rep. Alyssa Black (Chair)]: Okay. Alright.

[Susan Ridzon (Executive Director, Vermont Health First)]: Well, we'll actually direct. Do you want concierge or direct?

[Rep. Alyssa Black (Chair)]: Direct is fine also. I sent you a couple of Trying to trying to get everyone's perspective on this. Alright. So I was I put on here committee discussion, we're frankly running out of time, and I don't want to go past noon today. So, Leslie, did you

[Rep. Leslie Goldman]: have that? Well, I'm just curious about this pay parity idea, and if that just want to understand it more and if it does have a place here.

[Rep. Alyssa Black (Chair)]: Does everyone have a copy of the bill? Yep. Can I the only thing I'm going to ask is, frankly, we're running out of time? Not on the calendar, not time on the clock. We haven't done any markup on this bill. It's been actually a couple of weeks since we even did a walkthrough of bill.

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: And

[Rep. Alyssa Black (Chair)]: we've taken a amount of testimony. I mean, I want to continue taking some testimony, but I feel as though we should get into the point where we might want to be thinking about marking up, amending, deleting, changing. I mean, just because it's on the page doesn't remember, that doesn't mean that what has to be on the page or we can't add to the page. We're doing our public hearing next Thursday. I really want that to sort of inform our work. So I'm hoping that everyone will take their hard copy home or if you'd like, greeting on your computer. And just spend a little time reading the bill yourself, looking at the bill, thinking about a lot of the things that we've heard, what your thoughts are. I'm looking for ideas of how anybody else would like to add, take away. That's really what I'm looking for. And we can, we'll pick it up next week. And also next week, I'll let you know, we got to move on to 190 also. Doesn't mean we can't be working them both at the same time, but S-one 190 is something, so we're going to do a walkthrough and start taking up that bill as well next week. Oh, and we have finished 189. All the stakeholders are getting together and going to give us some language, and then once we get language, then we will again make that decision after we see the whole process laid out on paper, we'll make a decision whether or not we want to create a convention or a order. That was the one thing we're tape lining until then. Okay, anyways, great weekend everyone, and we're done. Hope you're back

[Dr. Hannah Rabin (Family Physician, Richmond Family Medicine)]: Tuesday.