Good afternoon everyone. I'm going to call the meeting of the Green Mountain Care Board order. My name is Kevin Mullin chair of the board. Many people have asked if we would proceed with today's meeting today. We felt that it was necessary to proceed. And we as a board have been working remotely all week. And except for two people coming into the office keeping complete distances. We're still open to public comment and to everything else. And I just want to say before we get started in today's business that it's a very strange world which everybody is trying to deal with right now. And yes we are going to continue with today's meeting and take up the guidance. But the reality is that we are going to probably have to delay a lot of things. Especially the first timetable when it comes to hospital budgets is non-financial reporting which makes no sense for us to ask hospitals to do that rather than do what they need to do to prepare for the public in case we do have a larger scale outbreak in Vermont. And many believe that it's only a matter of time. Fortunately the state of Vermont has taken some very good precautions to start to get everybody to as much as possible work from home to follow strict guidelines. Restaurants are closed schools are closed and you know we have to really show some compassion to our neighbors. Especially those who aren't as fortunate as those of us who are able to work remotely through technology. And we know that if you're a worker at a restaurant or a movie theater or a hotel or any place of public gathering that you're going to have a lot of uncertainty. We hope the federal government moves quickly to provide some resources to everyone in the country. But in the meantime we as state employees will continue to work. Via remote and we will continue to move forward. But I just want to say up front that we will not just stick to what's happened in the past if it's our main job now to get out of the way of the people providing direct care. And even though we are proceeding with guidance we have to understand that we may have to put in place delays and that we're going to have to play this week by week day by day. And I don't want any hospital to think that we have not heard what they are going through. I've had conversations with both the head of the VOS board and with Jeff Thiemann the executive director for VOS and made it clear that we wish to help not hinder and that this is not a time for over regulation. This is a time for understanding and trying to help our neighbors and try to help hospitals through this process. It's going to be a tough process because in order to fully prepare hospitals are having to make changes. They're canceling elective surgeries. They're seeing a number of people canceling on their own from events that would occur at a hospital. And in some cases hospitals are going to have to shut down profit centers in order to create the capacity to take care of COVID-19 patients. So we understand all that. But at the same time we're going to move forward with today's meeting. And at this point in time I'm going to ask Abigail to take an inventory of anybody who's participating so that we can keep it for the public record. Abigail? Yes. Good afternoon. I'm going to just list out phone numbers that I have on our space invite. Please say your name, your title and your organization after I say the four digits of your telephone number. And there looks like quite a few. So I'll try to do this as quick as possible phone number 6778. Are you using the last four digits? Yes. Great. Good afternoon, Matt D'Agostino. I'm the manager of contracting and pair relations. You've got health network. Welcome Matt. Thank you. Thank you. 5001. Julia Shaw with the office of the health care advocate. Welcome Julia. Thank you. 2449. Welcome, Kathy. 2505. Jennifer Callis, Everment Relations at UVM Medical Center. Welcome, Jennifer. Thank you. 6376. Hi, this is Mort Wasserman. I'm a private citizen, Professor Emeritus of Pediatrics at UVM. Welcome, Mort. 7438. This is Ham Davis. Welcome, Ham. Hope all is well. Fine, Kevin. Thank you. 0915. Jocelyn Olduk with the Association of Hospitality and Health Systems. Welcome, Jocelyn. 3082. Urban Austin UVM Health Network, contracting. 0043. Becky Lewandowski with DRM. Welcome, Becky. I'm sorry, I lost my place. Did I just say 0043 or 2636? Yes, you did. 8878. Jeff Bertrand, Chief Financial Officer of Porter Medical Center. Welcome, Jen. 0193. Hey, this is Jeff Battista from the State Honors Office. Welcome, Jeff. 5835. 4675. That's Lori. Thank you. 8643. Patrick Rooney, Director of Health and Finance. 1 970. I think that's the office here. 8267. Lucy Garand, DRM. 3000. Somebody calling in from the University of Vermont Medical Center. Yeah. This is hard, but my name is listed further down as an individual name, not a number. Okay, perfect. Thanks, Mark. 5572. Thank you. 7081. This is Eric from HCA. Thanks, Eric. And it does look like we have a couple of people that might. It recognizes I see Susan Aronoff is on the phone. And Mark Stanfos and John Olsen. Well, welcome, everyone. Yes. So with that, I'm going to turn it over to Susan Barrett for the Executive Director's report. So I'm sorry. How are you doing? I'm good. Thank you, Mr. Chair. The Board and the public. Thank you for joining us. Online and on video. And for these very. Unusual and. Unusual and. Unusual and. Unusual and. Unusual and. Unusual and. Unusual and. Unusual and. Unusual and. Unusual and. Unusual and. Unusual and. Difficult days that we're all experiencing that I just will echo.  We know.  And I just want to say thank you for everything the chair said. Thank you, Kevin for addressing that. I do want to do data to these unusual times. I want everyone to make sure you check our press. And our. Scheduling for the month on our website. I mentioned it earlier, but if you go to the green mountain care board. Page right on the landing page, there is the board meeting. And you'll see. The meeting. Of March, as well as the agenda and the materials for each of the meetings in March. We already have a scheduling change that I want to announce. Our meeting schedule has not been updated yet on the. Website, but for next. Next week, we're actually conducting a certificate of need hearing. We'll start that at 9 30 a.m. that is located on our. Monthly, a spreadsheet, but in addition to that, if you scroll down to the second page, we have. In the afternoon scheduled an FY 2021 hospital budget guidance and potential vote. We're going to move up to the morning. We'll have the CLN will put that on the agenda after the CLN. And then we are taking off the agenda for now, the Blue Cross Blue Shield presentation. As I said, all of this will be updated on our website and on our agenda. But I wanted to mention that and just remind folks to please look at our website to look at what is on our agenda. And we're how we are conducting the meeting. I'm assuming we'll be doing this remotely for a while. I also just want to remind everyone to please mute their lines. It sounds like the lines are fine right now, but oftentimes you can get some feedback. If you are on the phone and the computer, so please mute your lines unless you're talking and unless you're a board member. And then the last thing I want to just mention is that if we do get disconnected, the number for this call in is on our agenda. And is also on the presentation that we will see here today and on our website. So if the video does go down, which you know, it's been running fine for for us so far. But as the day progresses, it may get busier on the bandwidth and we may have run into problems. So I just want to remind everyone to use the call in number supplied on the agenda today. And that is all I have to report it. I'll turn it back to you, Mr. Chair. Thank you, Susan. The next item on the agenda are the minutes of Wednesday, March 11th. Is there a motion? So moved. Second. Seconded. So it's been moved and seconded to approve the minutes of Wednesday, March 11th. Without any additions, deletions or corrections. Is there any discussion? Thank you. So at this point, we're going to turn it over to the hospital system. Finance team, along with members of our analytics team. And I understand that Agatha Kessler will be driving the slides, but Patrick, I'm going to turn it over to you. And the discussion is on the 2021 hospital budget guidance. Patrick. Yes. Thank you, Mr. Chair. Good afternoon, everyone. I'm going to do my best to describe this. Again, after ruining with the care board and my colleague Agatha Kessler will be presenting today from our data. We will have Sarah Lindberg and Lindsay kill. The guidance discussion for today is going to come in three parts. Part one will be the data teams presentation to the board. Following that around the patient flow analysis and total cost of care work that they've been doing. After that, we would like to hear from board members in the discussion relating to whether or not they see value in adding this component to the budget or would it be more of a support and supplemental document for their edification and better informing the decisions they're ultimately going to have to make later this year. Moving past that, we will actually get into the revised draft of the budget documents with feedback from last at our meeting. And then they this slide. And a status of those requests. And the reason we did that was because of some of the technical issues surrounding today's meeting. And if we don't have to toggle back and forth and confuse any lines, we'd rather not do so. So if there are specific items, once we get to that, that members would like us to highlight using the actual guidance document. And this is we're happy to do. I think there we review updated policies that part of the guidance. And then after that wraps up the entire discussion. We'll do a board discussion on the MPR FPP growth for the coming year. And after that, we'll cover enforcement and the sustainability plan. So we have a lot to discuss today. And with that, Agatha, if you could move into the next slide. I will turn it over to Sarah Lindberg and Lindsay Kil from our data team. All right. Yeah. Good afternoon. This is Sarah Lindberg Health Services Researcher with the Green Mountain Care Board. I'm on slide five of the presentation today. And what we would like to do is talk about three new reports that we're in the process of producing to help support. Okay. So the plan today will walk you through these three new reports that we're going to be producing to help support hospital budget processes. And as Patrick alluded to, I think the question before you is how much of this should be material to help respond to questions versus being embedded in the guidance. Now, I have lost the presentation, but I am nimble like that. Oh, there it is. Okay. So the first report is what we're calling patient origin. And that report, we'll go into more detail about each of these. But the patient origin report is probably the most closely aligned with the hospital budget process. And that's talking about hospital utilization over time. And that's talking about hospital utilization over time. And that's talking about hospital utilization over time for all patients discharged from the regulated hospitals. And that, of course, from our BUD data set, the Vermont Uniform Hospital Discharge Data Set. The second report is both closely aligned with our all-pair model work, and that is one that is called the all-pair model total cost of care. And that was included in last year's guidance. And it's been refined a little bit to include some additional detail by payer. But that is comparing, remember per month, total cost of care is defined by the all-pair model for the HSA of residents, the hospital service area of residents. And the final report is brand new and we're very excited about it. And that is one where we're kind of doing a crosswalk that compares the total medical claim spending that we have available to us in heat cures and mapping that from where people live to where the dollars were spent. Or the hospital service area of the rendering provider. So I think with that we can move to slide six. So here's a draft example of what the patient origin report will look like, and we're still kind of refining exactly the best way to deliver these reports. But just to walk you through how this would work, this is an example for CVMC. And the map on the left is showing for both inpatient and outpatient discharges. So discharges are much different than a claim. It's an event-based data collection. What proportion of utilization came from each HSA? So you can see 91% of the discharges at CVMC were from patients residing in the very hospital service area. And we'll also have breakouts that show it by payer. This is the table on the right is showing five physical year and payer type. And this will be the primary payer type. So of those vast majority of discharges from Berry, you can see in the first line on the far right for physical year 2019, 46% of those were primarily commercial payers. So we'll have one of these where you can kind of compare across the system but also within each HSA. So this will probably either be an Excel spreadsheet that people can manipulate or in some sort of interactive visualization or perhaps both. But we just wanted to kind of give you a flavor of what this report will look like. And if you want to advance to slide seven, please, I want to just highlight some of the strengths and limitations of this particular report. So the strengths that we see are that it's provider based. So this is the only one of these new reports that is based on where the care is delivered, which is how the hospital budget process works. So, you know, no matter where the patients come from, the hospitals still are having to address the costs and expenses associated with that care. It also is the only one of the reports that will feature all patients. So it doesn't have the limitations of our all care claims database seekers. So we'll have people who self-pay. We'll have workers' compensation. And the self-funded GOBE decision does not affect these data. It's also data that's submitted directly by hospitals through a contract we have with the Hospital Association NSO branch. And so they work with hospitals to help, you know, curate this data. But it's coming right from the hospitals, which I think is a real strength of this particular data source. However, nothing's perfect in this world. So the limitations are that we don't really have logical financial data in this data set. It only has charged amounts, which is not very helpful for a budget review.  So this will come up particularly when an outpatient practice is owned by a hospital. We'll only see the facility side of that claim. So we're going to be a little bit limited on what we can infer on the outpatient utilization side of things. So that's this report. Before we move on to the next, any questions I can address? Hi, Sarah. It's Maureen. Just a question on would we be able to get the number of patients when you go back to the slide prior? I guess if we look at the... So it will be the number of discharges. Discharges. Counting unique patients is one of those things that things like it should be so easy. And we're working on refining. But yeah, it's a unique event. So your high flyers will be 80%, the 80-20 rule. So we'll have the same person counted in multiple times. We don't have a distinct count of patients. But we're actively trying to think through a better way to address that issue. And then just to be clear for anyone that's looking at this chart, this is just not real data, for example. Correct? This isn't live data? It's not live. No, no. But it's the most recent we have. So it's through fiscal year 19. But it doesn't. If you look at the Brattleboro line, so how would we translate that? So this is just for CVMC. And maybe it would be helpful, Sarah, to explain what the numbers of certain HSAs are. Yeah, yeah. Sorry about that. Yeah. So yeah, you would have another chunk that looks like this for Brattleboro Hospital. So not a lot of people, it turns out, seek care at CVMC from the Brattleboro HSA. All right. So the next report, again, is the all-care model sort of cost-of-care report. So this is refined from last year's budget process. So what we've included here, and again, this is just a draft example. We're just featuring the very HSA. It's always fun to pick on the hometown HSA. But what we have here is the all-care, total cost-of-care over time, including a five-year compounding annual growth rate. So that would be the growth from 2013 to 2018, which is the most frequent, complete data we have available for that particular measure. This is on a calendar year basis. We have removed any non-claims-based portion of that because I think that money's in a little bit when we're trying to do this. I should say we are including the Medicaid, all-inclusive population-based payments, and the Medicare fee-for-service equivalents. But we are not including any shared savings or blueprint money. It's basically what it boils down to. And here we've also now added break-out by payer types. So you can see statewide you can see the total cost-of-care for the commercial Medicaid and Medicare populations, as well as what proportion of the kind of payer mix that is for the state. So in 2018, the Medicare total cost-of-care was $869 per member per month for the claims-based total cost-of-care, which represented 27% of the 5.4 million member months making up the statewide total cost-of-care. And then you can see below what it looks like just for people who live in Barrie. So this is, again, another important detail, but this doesn't mean that these people would attribute to the Barrie health service area. That's based on where the rendering provider practices to whom someone attributes. But for those who live in Barrie, this is what their total cost-of-care has looked like over time. Yeah, and we can actually go to the next slide, which would be slide nine, which will do a similar strength and limitation review. So the strength of this report is that it's the most aligned with our all-payer model agreement, which is one of the major mechanisms we're doing to try and meet the triple aim of healthcare delivery reform. And the nice part about this report is that it does factor in people who don't utilize care. So that means we can calculate rates. That's one of the trickier things in my book for a provider-based analysis is it's really more difficult to figure out an appropriate denominator. But since it's based on where people live, we can actually compute meaningful rates. Some of the limitations are we're not restricting by providers. So the total cost of care is going to include care from wherever it's delivered. So people who are getting care out of states are factored into this. So you may live in the Barrie HSA but get cared out in Boston. So it wouldn't necessarily be a fair reflection of Vermont hospitals in a case like that. Another limitation is that our all-payer claims database has certain exclusions. So we are missing people without insurance. We don't have people from out of state that are seeking care in our hospitals. And we have about half our self-funded market is not reporting to v-cears, although I want to give a shout-out to some of the employers who are now agreeing to voluntarily submit thanks to the board's outreach. The more data we're able to get in this thing, the stronger it is. Furthermore, the total cost of care is a more limited scope of services. And those provided by hospitals. This is most substantial for our Medicaid population, where about half the Medicaid care is excluded in the all-payer total cost of care. The other major one that always comes out in my mind is retail pharmacy. So drugs and supplies that are not paid for through medical claims are not in our total cost of care. So any questions about this report before I turn it over to Lindsay to describe our final report? Okay. Take it away, Lindsay. Hi. This is Lindsay Hill. Can everyone hear me? We can. Great. Thank you so much. So today I'm going to present, talk about briefly the patient migration analysis, which we are adding into the mix new this year. The table before you is an excerpt from one of the tables we are proposing to include. So this is not a complete table and this is not the only table we would propose. This is an excerpt of the portion of total medical spend for patients from their home hospital service area. So where their zip code points to in terms of hospital service area and showing where their medical spend occurred in terms of the hospital service area that the rendering provider was located in. And we also summarized these by the patient insurance record. And this is all for 2018 in this particular chart. But this is coming from our V-Cures database. So this is along what Sarah said. This is for everyone who has claims and who claims submitters submit to V-Cures. One example of how we would interpret what we're looking at here is the Middlebury HSA residents spent approximately 48% of all of their medical costs within their own HSA. And if you could click to the next slide, slide 11, I'm just going to go over quickly the strengths and limitations of this data. So the strength of this data set is that it is all medical claims. This includes a broader scope of services than what's included in our all-pair model total cost of care and those captured in the hospital discharge data set. This includes the resident and the provider information. We are mapping where patients live to where their expenditures occurred. So this is really showing a high-level pattern of care that we can compare HSAs to each other and across time. The limitations of this, of course, is that it's not restricted to hospitals. This will include all care for providers in the hospital service area. But that limits its application for hospital budgets. This is all-pair claims data only. So again, the people that are not included in here are those self-pay, those from out-of-state or in any self-funded groups that are not reporting. And lastly, we have some limited services because we're only using all-pair claims database. We do not have non-claims-based spending. Are there any questions about this data? Okay. I think we can take it back to talk about the last slide, which is slide 12. So just our next steps on this workstream are that we'll make these reports available on our website. And as always, we will include downloadable data sets, so that people can manipulate them in whatever way they see fit. We will refresh these reports annually at a minimum. And we may incorporate additional detail, but we just need to balance those requests with other planned analytical priorities. We're really trying to work on honoring a lot of complexity coming up. And we just need to make sure that any additional information is balanced with that workload. So I think with that, that would conclude our portion of the presentation, so we're happy to address any questions or concerns before we turn it back over to Patrick and his team. Questions for Sarah or Lindsay, anyone? I just wanted to say thanks to both Sarah and Lindsay. This is information we've been looking forward to, so it's good to hear from you. Thank you, Mr. Chair. Thank you, Lindsay and Sarah. We appreciate you taking the time to help us present that. So not that it has to be done now, but before the final vote, the health assistance finance team would like some direction from the board on whether or not that information should be included in the budget. So my ask would be that you please take that into consideration between now and then we'll move on to slide 13 titled draft number two budget guidance for everyone at home. So this is the inventory that I spoke of earlier where on the left-hand side you will see where and in which document the requests last week were made and on the right you will see the status of those requests whether they were included or whether it's something that we already asked for and analyzed or what happened. So I will touch on a couple here right away and one was first gross charge, change in charge chart and the appendix she had asked if that was something that we could do and the staff thinks it would be best to revisit that post budget. So for next year we want to ensure that all parties understand the information being compiled and that it's accurate so that we don't provide any misleading looks for our hospital. So that would be our proposing that we move to the next cycle moving down we have the part two narrative it's number three from the bottom ACO participates in healthcare reform and this was an item that both board member Yusuf and board member Pelham had inquired about as to gauging where the hospitals are with their NPR FDP ramp up and where they fall in time frame of getting further and further on into the all payup model and we recommend that we further discuss this with other themes like our ACO and policy team and also perhaps we pose a question similar to that when we send out the staff analysis later in the budget process so that begin to get a feel for where the hospitals are without actually putting that in the guidance this year so that's the status of that and how we're proposing it underneath that is the healthcare advocates items that go along with some of their questions and we had sought them out earlier this week some historical information could be folded up that's already been asked and what did see before we came on the meeting that I got a reply from Julia Shaw healthcare advocate I've not had a chance to read that yet so there could be some information in there that I'm not privy to at the very bottom under general is a payer reimbursement assessment tool we have been working on this this is a commercial to Medicare charge ratio and Medicaid to Medicare charge ratio it was originally brought up in last year's budget hearings and we've been working with the hospitals to refine what that is and that's something that we can offer as a support tool for our board members as we receive budgets from the hospital the remainder are items that we accepted and included in either the appendices or the off-cycle reporting or made red line changes to in the narrative now again the reason for this inventory is so we could limit toggling back and forth between those various documents and the presentation here so at this point I would pause and ask board members if there is any item on here that you would like us to show you in those documents we can certainly do that so Agatha has direction on where to go from here board members now this is Maureen I also had a talked with the budget team in agreement with moving some of the requests I had to next year so just want to concur with that thank you Maureen any other board members well this is the short one and it's not specific to these items it was Patrick introduced him he was interested in what the board might think about the 18's presentation being included and I'm just wondering if he could give me a couple more sentences on that since this is work that we're doing and it may or may not be helpful information to hospitals but what would be a reason that we wouldn't include it as available information in the process so we talked with the A team we discussed as you saw the kind of the benefits and the limitations of the information and we just want to make sure that it's something that you all want to keep paying attention to as it refined then that's great and our question was does it belong in their budget process this year does it influence any of the decisions they're making as far as building budget or is it just a supplementary thing so we just want to know because it's new information not everyone at the hospital has seen it yet what direction would the board like the staff to go with it because we want to make sure that you have every available component of information to make the best informed decision that you can but this information is very new and we want to be conscious of the fact that there are limitations to it so we don't want to supply anything that could potentially misinform so if the board sees value in having this added to a component of the budget submission please let us know where you would like that document to be placed and we can go from there this is Patrick this is Agatha do you mind if I follow up on that question from Tom please just from a budget guidance perspective the question would be do we include a question or a series of questions related to the materials you just saw or do we have a supplemental document that's used after the budgets are submitted so that's kind of why Patrick is closing that question right now as we're looking at the budget guidance this is Jessica can you all hear me yes okay great in my own thoughts on this I think that the materials that the AT&T put together support that's fantastic I think they will help us shape kind of a better understanding of what's happening in each HSA I look at them in the same way that I think about the payer reimbursement assessment tool that's on the bottom of the table that Patrick was just going through but I think at this point our hospitals are inundated with caring for patients in the community and my sense is adding more questions to guidance is not prudent right now I think that we can certainly use this data and understand the limitations of the data as we're understanding their budgets and their budget submissions and certainly sharing any of this data reports with the hospitals and the general public will be useful but I would not advocate adding more questions to the budget guidance right now thank you for that Jess because I think that this is a year that we have to be very sensitive about how much work is being created for hospitals as they're dealing with what we're all experiencing out there so I appreciate those words and comments from Robin I'll jump in I agree with Jess I think it needs the guidance needs to be clear that we may consider it as background information but I don't want to ask anybody to I don't want to ask any additional questions I think one of the things that is a little bit hard for me in thinking through this presentation right now is that as Kevin said at the beginning we haven't really yet had a chance to talk about kind of what we're thinking about in terms of moving forward and so I for me there's like basically two ways to go or two potential ways to go and one of them would be just pushing the whole process the other would be skinning down the process and I don't think we know today what we should do or what makes sense given the situation so I think this looks fine with the caveat that depending on where we end up with the emergency and how long that lasts we may have to revisit the guidance I think we have to decide the guidance in the future so whoever is not on mute that has the background noise if you could put it on mute it would be very helpful to follow up on what Robin has said one thing that I'm pretty clear on today and I might be wrong and I hope I'm wrong but it appears that the non-financial reporting should probably not occur in the next few months and I would like to get feedback from the board at some point on where the rest of the board stands on that but I don't think this is the time for us to take valuable time and resources away from the efforts in the field this is Jeff I agree it's Maureen I agree as well Tom or Robin it's just Tom I'm on board with that I think as people refer to this black swan that has come our way that the amount of upheaval that we anticipate that we don't even know and so if I were to go in a direction I would go in the one that Robin suggested which is less is more at this point in time but on the other hand if there are opportunities out here to improve the existing infrastructure that we have as a friendly part of this process it wouldn't be totally close to it but my general sense would be people up to their ears and alligators and less is more here I agree too as one of the people who probably most heavily uses the non-financial reporting I feel like we'll figure it out but we shouldn't be asking people to submit anything I may first I had another thought on the timelines and I don't know if they're out there Kevin or if you want me to wait until we're farther along with the presentation well I'll let you use your good judgment if it's along the conversation that we just had throw it out but if it's relative to what's further on in the documents then wait it's specifically relevant to the timeline and so one of the questions that I posed to Mike a few minutes ago and I apologize to him for not understanding but it's just really my thinking involved this morning was whether or not in the budget guidance document itself where we have the timelines laid out if we should instead of having specific guidelines basically delegate authority as a board to use Kevin as the chair to determine the guidelines as appropriate which gives more flexibility to figure it out in real time as we get more information we also one thing we did look at is the guidance by our rule it has to be issued by the 31st but that is not in statute and we do have the authority as long as it's not routine to waive our own rule so I would also wonder if it might make sense 31st for guidance which would give us more time to see how things evolve and determine whether it makes sense to push the whole process within statutory limitation or to skinny the process if we're not able because of the statutory limitation and I'll just note on that piece the main statutory limitation is that by law we're required to make a decision by September 15th there is currently a bill in Senate Health and Welfare related to COVID-19 and they will be thinking about whether or not to give us the authority to waive that but that's not maybe you might want to put that into a much simpler motion people would be open to pushing the guidance waiving the March 31st rule to push the guidance beyond that date maybe that's the first question maybe we want Mike to weigh in on that Mike Barber are you capable of weighing in at this point yeah so I mean I agree with everything Robin said she kind of captured our discussion the rule gives the the authority to waive provisions of the rule to prevent unnecessary hardship or delay to prevent injustice or for other good cause and so like Robin said the March 31st for the guidance is in the rule it's not in the statute so if you guys feel that one of those conditions is met there's good cause to waive that you can do that and I guess my thinking is I don't want to create more uncertainty in terms of the process but given the amount of uncertainty out there it just seems like if we're not able to shift the statutory deadline I think realistically we're going to have to skinny down the guidance significantly from where it is today and just really pick what we focus on I think maybe pushing it makes sense so we have a better idea of which of those two options are available to us I think it's I don't have an objection to moving it out however I think we will need to find out get an understanding of how long we want to move it out what that's going to mean and things like that because we don't want to push it out for whether it's months, six weeks, eight weeks and then turn around and say okay we want all the information by September so I think we need to probably have some discussions with the hospitals on some framework my concern would be we move it out two weeks and then we don't change everything dramatically down the road as to what the deliverables are so it may even create more uncertainty knowing that we could set the guidance right now on the path that we're going on and understand that yes things are in flux and could change very quickly down the road so what else would you like to hear other people's perspective on that as well well I think that you know we need there's a lot of unknown here and in the context of all that unknown we need to be agile and I think that the board has a very collegial relationship we're all interested in doing the right thing I think Kevin has his ear to the ground in terms of issues that arise and what's going on out in the hospital and and so I would be open to not bending the rules here but amending the rule that applies this year so that we can move quickly and because we can well but then you get into this issue of the open meeting law where we three of us can't be in the same room at the same time so we're shooting we argument the foot here but I would go the agile route as best as we could within our statutory guidelines I guess in my mind we want to maximize flexibility and I think we want to minimize uncertainty for the hospitals and minimize the burden with for them right now as they're trying to manage a public health crisis so we need to be nimble I think I'd be in favor of waving that aspect of the rule but I hear what Maureen is saying in terms of we don't want to add more uncertainty to any process because uncertainty is problematic so I think we want to convey that somehow some way that hospitals will have enough we're trying to help the hospitals in this process by doing this by streamlining guidance and having flexibility with the guidance and then the deadlines can minimize their burden as they're trying to deal with a public health crisis so Robin I would like to throw the question out to Vaz about their opinion on this and it may be unfair to put Jocelyn on the spot but maybe you could raise some type of motion and then I could go to public comment if there's a second sure that the board wave its rule that hospital budget guidance must be issued by March 31 yeah I'll second it so it's been moved and seconded at this point in time I'm going to open it up for public discussion is there someone from Vaz that would like to address this issue or possibly one of the hospital CFOs that's on the line so first of all thank you for taking up this important conversation at this time with the uncertainty that we're all dealing with I mean the health networks support creating the most flexible, feasible process for the budget as it's been said earlier we think it's the board members consider this decision and some others coming up in the near term that to just understand the current priorities of the hospital our employees and our communities that we serve and in doing so well it might not challenge immediate policy within their current I can tell you our focus is first on the public we promote stability to our employees and our communities at certain times and we're keeping this in mind for a year on our covenant violations or covenant testing in hope to avoid any covenant violations and that might require some immediate action now and from a budget perspective for FY21 I candidly have to say that is way down the list right now so it is difficult at least from the hospital or with a budget perspective to say how we would care board put out but that's where our priorities are so we would obviously promote as much flexibility as possible within the guidance of the rules and the statute but you know I can't speak for all the hospitals I can speak for a few of them at least the FY21 budget is like down on our priority list is still very important but it is way down on the list right now we understand that it has to be your number one priority in addressing and I think that's the real intent of the motion that came from Member Lunge is to try to put some more flexibility and nimbleness into the process Mark was that Jen that I heard start to speak Yes it is Chair Mullen it's Jen Versran I would certainly echo what Mark is saying and I will caution that myself stepping in as section chief as part of incident command as CFO such as supply chain which as you can imagine has quite a strain on it currently it's certainly taking up perhaps some of the small organization CFO time and try to focus on those budgets in addition to unfortunately we have members of our own teams I can speak to some here at Porter who are now and obviously set up to work from home not with the COVID but just as precautionary having them stay at home which then creates a little bit of bandwidth issues as you can imagine and taking away focus from the budget process just some of the outer lying things that we're focusing on I'll be frank since March 9th this is the first time I've been able to focus on anything budget related if that helps and so we certainly appreciate anything the Board is doing to help with those delays focus on the immediate need at hand and as several of us has said Jen already that we want to help not hinder thank you thank you for all that you're doing there was an excellent front page picture of the Porter drive-thru on the cover of the Rutland Herald this morning so and it's quite busy as you can imagine we're getting a glimpse of what life is like for you are there other members of the public who wish to comment hi this is Devin Green from the Vermont Association of Hospitals and Health Systems hey Devin just got texted about what was happening so I hope I'm commenting on the right thing but we do support waving the deadline for hospitals great that wasn't what we were talking about but that's okay no I'm just kidding Devin trying to add some levity into some trying times trying times for sure but yes we really appreciate your efforts on that and it will alleviate a lot at least one piece of the pressure that hospitals are dealing with right now okay is there other public comment Mike Fisher here hey Mike Mike Fisher out here I think that the approach that's laid out in this motion also I also think it makes sense and I also think it makes sense to further create much nimbleness in the voice decision making process apropos delegating some authority to the chair so that you guys in a process that can work given the evolving nature of this thing thank you Mike other members of the public not hearing anything else is there any further comment from board members hearing none council barber could you call the role on the motion yeah I could just restate the motion as I heard it would be to waive the March 31st deadline for the issuance of hospital budget guidance for fiscal year 2021 was there also anything about delegation in this motion or is this strictly the waiver of the timeline so I think that would give us either more time what we want to issue with guidance or we could go ahead and do some delegations today too but I thought maybe we could take those as separate conversations member homes yes member lunch yes member use for yes member Ellen yes Mr. Chairman yes so with that I'm going to turn it back over to Patrick thank you Mr. Chair and as you all know but the members of public should know as well that staff here who have compiled this can adjust and be as flexible as needed as this process evolves given the current state of the event so with that we're going to move into slide 14 which is an update of the policies that are part of this process as well and I will turn that over to Agatha Kessler thank you Patrick so we're on slide 14 of the slide deck and we're actually going to jump to a second document that's posted on the website we're going to take you to the text of the policies themselves so for those of you who are following online you can see the new document up on the screen for those of you who are using the documents on the website this is the combined guidance document and we are starting on page 15 of that combined guidance document this is where the policies start so to review we're going to go over three policies with you the exemption from public hearing the budget adjustment and Appendix 9 the budget adjustment and then Appendix 10 is for hospitals that are requesting a budget amendment so back to page 15 on the combined document the exemption from public hospital budget hearing has not been substantially modified it's been updated the piece that has been updated is in the criteria staff are suggesting that we include explicit instructions that the budget in order to qualify for an exemption would also have to comply with all content and submission requirements so that's just we would categorize that as a cleanup addition Appendix 9 is budget amendments and adjustments this is an example of how the guidance document was reorganized we took some policies out of the budget guidance document itself and gave it its own appendix this policy sets forth when a hospital needs to have an approved budget amended if in the course of the year they have a provider transfer acquisition and that same sort of criteria applies for when a hospital would like the board to make an adjustment in their submitted budget so I guess the best example is if a hospital acquired the practice in February of a fiscal year we would describe that as a budget amendment they would have to amend their approved budget order for the current fiscal year but if a provider transfer happens let's say in July we would not amend the current year budget order and instead ask the hospital to include it in their annual budget submission and it would be considered an adjustment a new concept here that is something that we'd like to prompt the board to think about is as staff we see a variety of interactions and correspondence with the hospitals about things that are potential provider transfers or things that might be an expansion of a service line because of recruitment and as staff we see that they vary in scale from small adjustments that are less than 1% of NPR all the way up to larger adjustments and what we wanted to prompt the board to consider is whether or not the board would like to include any language and these adjustment policies that would capture a reasonableness threshold so for example if there's a change in a hospital that is below a certain threshold then it would not be expected that the hospital would request an amended budget order although it would be expected that the hospital would report it in the regular monthly year to date reporting you'll see here that there is a place saver for a threshold figure this is simply to prompt for discussion on this topic it does not need to be a specific value it could be a narrative so to speak with words like reasonable or significant but to flag that issue for the board continuing on we've cleaned up the independent provider acquisition and transfer policy to reflect what the board has used how the board has used this policy in the past and how the board may want to use this policy in the future to put it simply the policy as currently written applies strictly to independent practices that are acquired or transferred to the hospital so if Dr. Smith is independent one day and then works for the hospital the next day it would fall into the provider transfer policy however as we've seen the board has come into cases where it's not necessary that Dr. Smith is practicing one day under one roof and another day under another roof it could be that Dr. Smith closes the practice and now those patients don't have a home anymore we've seen where hospitals have then expanded their service lines to respond to that gap and service in the community and the provider transfer policy has been used so we've incorporated the word service into this I think what really captures it here is this highlighted piece that this policy applies to the acquisition of an independent healthcare practice hospital divestment of a healthcare practice and a hospital's response to the anticipated gap in service when an independent provider leads the community scrolling down we've added a new section about accounting adjustments this is not a new practice it's just that we are now putting it down in writing that when a hospital has an accounting adjustment that affects their budget we have a policy now that more clearly defines the expectation to report on those and then finally the amendments to approved budgets in section D outside of a provider transfer acquisition a hospital as you know can request an amended budget order and so we've included this in the overall adjustment policy and have described it as unanticipated changes to an approved budget for example request for interim changes in charge or unforeseen changes in utilization any questions on the policy of providers of adjustments and amendments questions sorry Kevin this is Robin my question was actually on the budget hearing waiver process so we had indicated and we did this last couple of years that we weren't doing exemptions I would think we'd want to give ourselves the flexibility to allow for waiver of budget hearing so for example we aren't able to get flexibility in the September 15th statutory deadline but it's not reasonable to do full-blown budget process we may want to waive some hearings and that kind of given the circumstances so I just want to make sure we maintain flexibility there I agree with that I think we should have flexibility to exempt hospitals from the budget hearing and the circumstances so just as that's heard when we look at what the criteria is we already rule out the top four hospitals and of the remaining 10 hospitals I'd have to look but I think most of those 10 are losing money or are missing their budget so we just have to be careful it's not that I don't want to put a waiver in place and not review hospitals but the ones that will be concerned are the ones that are really hemorrhaging on the bottom line and so I would be careful about you know if they comply with everything sure but in the past some of the ones that have asked for the waiver are the hospitals that are the most financially at risk so you know I think we're just trying to stop from the upper right and just say I think we want to remove that box where we're saying there will be no exemptions I think that's what we want to eliminate, is that right? Thinking but maybe to Maureen's point we also wanted to make it clear that this policy thinking like not as usual when I'm talking I'm talking about that box but also like we have to do it by September 15 but it's not we don't have enough time to do multiple hospital budget hearings and so for this one year we're going to just get through it and then go back to a more normal process so I just want to make sure we have we can be nimble in an extreme circumstance as well as you know as what we would normally do because I agree with you Maureen like I think the small hospitals are probably the ones we really need to see in a normal if we can do some sort of a normal process this year. I do think we're going to need flexibility in the whole process I just want to make sure as if I were on the hospital side and I'm going through this most of the hospitals that are you know could qualify because it's not the four charges almost all of them are losing money and we would expect that probably we'll get worse with what's going on so we may need to streamline things but I think we need to be in the loop and informed and so certainly we can take that off but there may be ways also Maureen to be flexible so that we're not dragging people to Montpelier so I think that as long as we keep in mind that we should be keeping flexible just removing that box shouldn't be that big a deal. So that's fine. I also hope that as our elected federal officials are contemplating relief efforts to certain industries that they put at the top of the list are frontline health care providers. Other discussion? Seeing none. Okay so we'll take that feedback on appendix 8 back to the budget team Lynn who is council who's assigned to the hospital budget team to figure out how we can ensure that they're flexibly in this exemption policy. The last appendix 10 is about budget performance and enforcement which is actually the next topic that you'll be hearing from us when we conclude budget guidance so you'll see this language again shortly. This has been really just for highlighting that the board will have to make a decision on what the acceptable range is in terms of if the hospital has a budget variance greater than X percent than they would be subject to review. Those are the updates on the policies. Any questions? Just one comment on this part of the policy when we look at that number two where we're focusing on if they're above or below NPR and I think again 10 of the hospitals were below NPR and then of those many had operating losses that were much greater that have been projected so there might be a way to also incorporate that factor in meaning if a hospital I think there may have been one hospital that was below their NPR but they were able to maintain their profitability so that may be one we don't want to look at so we may want to consider something like that as well so if we set up a guideline that said we're going to look at everybody that was below 3 percent but if they were below 3 percent and they also were able to maintain their profitability it wouldn't be as much of a concern and again I know we may be flexible on this due to the timing but one of the focuses we've been looking at the past couple of years has really been those hospitals that were missing the top line and bottom line pretty significantly and trying to prevent further situations in the future of bankruptcy and things like that so but it may be something to think about when we talk about the enforcement discussion okay other comment Agatha? Okay great so now we're jumping back to the PowerPoint presentation this is slide 14 that we're finishing and we'll move on to slide 15 turn over to you Patrick thank you so that wraps up the guidance review portion of the meeting and now we're going to transition into the NPR FFT growth for the coming year and up on your screen on slide 15 we have some of what was established in fiscal year 20 budget guidance and in bold some of the language that surrounds those decisions and this is strictly a board driven discussion we have this up here for you and slide 16 we have proposed language for motion so we can take it back to slide 15 and the actual language that was in the budget guidance from last year and turn it over to the board for discussion on NPR growth for the coming year who would like to start I guess I'll go ahead this is Robin given the uncertainty and the for the remainder of this fiscal year going into next fiscal year I think just sticking with since last year our goal was to set a two years target we should just stick with what we had last year because it sort of undermines the point of establishing a two year target if we're not sticking with it that's my thought understanding the target they get totally thrown out the window other thoughts I agree with this is Tom I agree with Robin in the sense that it's an unknown and we could restructure this in a number of ways but many months down the road kind of look back and say holy cow you know we were looking at 2020 it's coming in at certain levels and they're way way above it and using that as a base just doesn't make any sense anymore so I would I would leave the language in that's there that gives some guidance but I wouldn't die hard about those parameters because what's going on out there in the field is a total unknown and you know the process that we had set up was one that was set up for a more routine and regular environment and this is certainly not that this is Jessica I agree I mean I think the reason that we set a two year target was to give predictability to the hospital so to the three but we're living in a world of unpredictability right now completely so you know one thing I'm looking at the slide here and you know there was some question about whether we give a two year growth limit target and I would say we should just stick to this year and this year alone because we don't know where we're going to be a month from now six months from now and certainly a year from now we don't even know where we're going to be tomorrow if I'm being frank and so I think I'm comfortable with putting a 3.5 if that's what everybody else agrees so that's what our two year target had been but I think we need to add some language in here that recognizes that you know there's a situation evolving in terms of a pandemic and we need to be flexible with respect to the hospital budgets that are submitted and with respect to this NPR cap meant to think we need to put it in writing that we recognize that the times are changing and you know we may put this cap in there but we recognize what the hospitals are going through right now those would be my two cents so if I could summarize what I've heard so far in case somebody wishes to make a motion is that it would be a one year target only that the board recognizes that even setting a one year target may not be realistic but is doing so but will be completely open to dealing with changes as they occur as hospitals learn more about what they are dealing with in that in addition to the 3.5% growth limit there's also the 5% growth limit for hospitals with budget to budget variants less than 2% with the same caveats that it may be irrelevant but that for the purposes of setting this guidance forward those are the base parameters is somebody willing to make a motion I just wanted to say one more thing I mean I really hope that whenever the budgets are submitted if that deadline is extended my hope is that the budgets that are submitted are based on the circumstances that the hospitals are in the most up to date current information that they have the most realistic budgets that they can put together at the time that's what I'm hoping that we see so if we can convey that as well I think that's important yeah I think another factor as well is how are the hospitals altering their process because we were just one piece of that process they have hospitals they have a process with their board and with their internal committees about when they're forecasting for the year and I don't think it's all driven just by the regulatory process so understanding what they're doing as well to give them flexibility but are they just not doing that or what are they representing to their boards and how are they going to be managing their budgets because they're all in all for the flexibility and moving things out we also know that the budget is irrelevant from day one and it's a forecast that they will measure that they will look to change each month and their fiscal year isn't changing right so they're starting October 1st no matter what that's their fiscal year and they have other things with bank covenants and things like that so there are requirements that they're going to have as well they're going to need to gather a budget just putting that into perspective as well we can say they don't have to come to us we can talk about being really flexible we can talk about moving timelines but their fiscal year isn't changing and they're going to come up with actuals through September and a new forecast through October and I guess getting a better understanding of what they're going to be doing I know their focus is kind of beyond other things and I know we need to be flexible but at the same time they have to make sure that they're solvent and that they're putting their forecast some type of forecast together to understand what's going on so their fingers also will be on the pulse on this too so I'm perfectly happy to be flexible to go with the three and a half when you look at the language on the last page at the bottom we do get flexibility to go over three and a half percent if it's justified we open that up for last year we look at each hospital's individual circumstances when they come in and that helps to to guide the process you know as well so I think we need some more information from the hospital groups as well as about what they're doing with this process so Robin are you prepared to make a motion yes I think so so we back one slide I just want to take a quick look at this try we'll see I may have to do two tries I move that we establish budget to projection variances the language in the fiscal year 20 budget guidance and recognize the pandemics and emergency circumstances in request for variances but I think that gives us some time to word miss the actual language in the guidance is there a second thank you further discussion if not again I'm going to open it up to the public for public comment before we take a vote is there anyone from the public who wishes to comment again this is Devin Green from the Vermont Association of Hospitals and Health Systems and we do appreciate any flexibility you can offer on this so thank you thank you Devin other public comment seeing none is there any further board discussion otherwise I'm going to turn it over to Council Barber for a roll call yeah this is Mike can I just ask one clarifying question about the motion you may so we're talking I think about a one year target the second year of the two year guidance that was issued last year is that okay so member Holmes Jessica member Yusuf member Lunge member Pelham yes Mr. Chair okay Patrick back to you Mr. Chair so on slide 17 we have next steps of course with our discussion today this slide will the items on the slide certainly need to be adjusted as we wait for board or legislative direction on guidance and final vote et cetera what not so we'll move past that now and move into the enforcement discussion and again I will turn it over to Agatha thank you Patrick so we are on slide 19 of the slide deck this is moving back to the board we have directions now for the board away from FY 21 budget guidance and talking about FY 19 budget performance and enforcement so what we're going to do over the next several minutes is review the timeline of enforcement the policy refresh you on the FY 19 year end result which you saw in a February board meeting we'll show you a couple slides that we're calling enforcement analysis that will show you which hospitals we're going to look at and then talk about next step so this is language from the FY 2019 budget guidance for budget order in the FY 2019 budget guidance the board established a 0.5 percent threshold where if a hospital is above 0.5 percent or below negative 0.5 percent that they would be subject to review to remind the board last year the board was looking at a very similar guidance and the board chose to broaden that range to positive 2 percent down to minus 2.5 percent timeline as we said is you review these results at the February 26 board meeting you're discussing the policy today you'll be establishing the threshold today and any hospitals that are subject to the established threshold would be called in April for an enforcement hearing this slide 21 is a recap of the FY 2019 result showing the hospital approved budget their actual net patient revenue for the year their budget variance and then in the right hand side you see their operating margin again reminding the board that the analysis that we've done in the previous slide is a graph showing the visual representation of that same data showing the budget to actual variances this is a nice look because you can see pretty quickly who's above and who's below the next two slides are going to show you hospitals that would be subject to review if you use the plus or minus half a percent trigger or if you use the plus two percent minus two and a half percent range so with a plus or minus five percent which is how the guidance is written you'd be calling in all hospitals or reviewing all hospitals except for Brattleboro Memorial and Porter and the next slide shows again if you're using the two percent to minus two and a half percent in this case you'd be bringing in a much smaller or you'd be reviewing a much smaller group of hospitals hospitals in blue are the hospitals that would be subject to review do you want to take Agatha or wait till the end sure absolutely I would just say that if we're consistent with past practices a number of these hospitals would really be addressed in next year's budget not in enforcement as a significant number are meeting the underthreshold and not the overthreshold and at least my perspective is that calling anyone in for a budget enforcement hearing within the next month is just totally the wrong thing to do when people are trying to address the crisis at hand but that's a thought from just one board member two board members three board members three board members we have here Chairman Mullen the Q1 results for the hospital so taking a look beyond the FY19 year end which concluded September of 2019 as you can see it's a different look for some of these hospitals if you're looking at their first year or their first quarter results for this fiscal year so we wanted you to be able to see that side by side this is what brings them the decision before you today in terms of their budget variance versus how they're actually doing this year the one that really stands out is northeastern as the one hospital that exceeded their budget variance by 3.8% as you can see in the first quarter of the year they're minus 4.0 this last slide and this is very much in line with your comments is that a staff what we're recommending at a minimum is to expand the trigger above the half percent to consider that Q1 year to date performance to consider operating margins where these hospitals stand in terms of their financial health but also to consider the amount of work that's already being done to monitor the hospital in terms of the monthly monitoring and the sustainability plan so that to some extent supports what you just expressed at this point it's up for committee discussion so again I'll start off the discussion just by saying that I think that any enforcement hearing in April is appropriate and I believe that we could deal with any problems that we see during the budget process and now's not the time to be penalizing anyone but with that I'll open it up to the rest of the board also on staff recommendations I mean somehow my type knocked me out like right as Kevin was talking so I think someone's pushing me off this on the budget but on the staff recommendations I'd also like to see where and I can't emphasize an email on this where their 19 actual came in versus their 19 projections so just to understand if things got better or worse from their projections when they submitted the 20 budget I think would also be a good thing to look at you know as far as bringing in for enforcement here in April I agree that's not the time to do it I would say though you know the hospitals that concern me the most are the ones the 10 hospitals that are missing their budget and I think it would be good also to look at what their operating margin budget was compared to where their actuals were we can see their actuals are in the red for most of those hospitals and I don't you know I think part of this isn't trying to penalize the hospitals it's trying to look at those hospitals that are missing their top line budgets and their bottom line budget and entered 20 with potentially unrealistic work tasks on the top line you know it's just going to continue to lose on the bottom line obviously now we have a lot of other circumstances that aren't going to help that but understanding what ramifications that could have for some of these hospitals again that are losing you know 5 to 10 percent each year so and I would just say on that marine that of those hospitals that are in that situation they're all I believe that every single one of them is under the current monitoring system that's been in place with Patrick myself having conversations with them on a regular basis and I think that you know when you look at strides that have been made you know once in a while it's good to do a good pat on the back and in a year ago at this time if we had to say a hospital that we were truly truly worried about would have been Gifford I managed to bring in a positive operating margin they're still struggling with their revenue side but that still is something that is a true accomplishment and I think that we can deal with it with that monitoring letting Patrick and Lori try to offer any assistance to them but without trying to call them in and create uncertainty for them and spend time on preparing for a hearing that's kind of where I'm not saying that we're trying to penalize them I'm just saying that sometimes we need to as regulators get out of the way because this is a really an existential or an exogenous event that we need to be helpful and not hurtful on No I agree with that and Gifford was the hospital I was talking about that came in lower on the top line but was able to make other adjustments to actually improve where their bottom line is coming in the key thing we know at a lot of these hospitals their fixed expenses can't really move too much and so once they put in where they think they're going to be on the top line they build their staffing to that level they miss the top line they miss the bottom line and it continues to happen and so I think right your monitoring is helpful with that so I'm okay with that I'm just saying I think we need to at least understand also where they came out versus their forecast for 19 and then looking at what that means for 20 and what that changes for 20 for the full year Other board members Yeah this is Jessica So I agree with you Kevin that bringing any hospital in for enforcement right now is not the right step and we need to get out of the way I'll let the hospitals do what they need to do to care for the patients I will say when this passes and I believe it will and I'm optimistic that it will I am worried about the hospitals on the other end of this we can expect shortages in supplies shortages in staff driving up costs more than they have been already Revenue as you know patients are not going into the hospital now for fear of contracting the virus and hospitals are you know eliminating or eliminating elective surgeries those tend to be high-margin surgeries so I really do worry about where our hospitals are going to come out on the other end of this so the monthly monitoring is going to be important to the extent that they have capacity to be submitting those reports I think we have to also be flexible on that maybe phone conversations I'm not sure but you know the sustainability plans when we get to them and when they become are going to be really important but so I agree with you Kevin on the not doing anything enforcement wise in April or any time soon it's going to be a very challenging year when we actually are able to do the budgets but also rate review because one has to assume that there's going to be pent up demand for services that are being delayed and these are all questions that are going to be very difficult for everyone to quantify and yet we're going to have to try to get through this as best we can other thoughts Robin, Tom I agree with Maureen that we should kind of button up the end of the 2019 data but I think anything in 2020 is going to be so one time that it's really no basis for enforcement because this black swan showed up and changed the circumstances completely so I think that having a good understanding of what the underlying dynamics were through 2019 and as kind of a platform and then 2020 we're just going to have to start kind of from scratch and work our back toward a reasonable trend line Robin? I agree with what everyone has said I don't think enforcement makes sense at this point Would someone like to make a motion? I move we waive enforcement for all hospitals for fiscal year 19 discussion if not I'll open it up to the public for public comment This is Devin Green from the Vermont Association of Hospitals and Health Systems again I appreciate waiving the enforcement for hospitals even though the folks who put together this information are not on the front lines of care they're really busy doing things like keeping supply chains open and everything else so again I appreciate all the help that we can get during this time and if I could put you on the spot not for an answer today but if you could follow up with either a phone call or an email to me afterwards during our monitoring of the conversations of the legislative bill on COVID-19 one legislator made the statement that hospitals could have a liquidity cash crisis within a short period of time that is not what we've heard from any of the conversations that we've had from any of the hospitals so maybe if FOS could just kind of try to define if they see any particular hospital with a liquidity crisis if they could let us know We can certainly do that Thank you Devin Other members of the public for comment Hello Kevin this is Mark I think on the liquidity crisis what's going to be first what's going to trigger potentially a covenant violation so while that may vary between the hospitals at least from the health network perspective we're not seeing any liquidity as far as making immediate payroll or anything like that but there's certainly an eye on the mark the stock mark is down another 10% as we sit here right now and you know so I think what the liquidity measure is going to be as it relates to any covenant thresholds Certainly that's going to be problematic as the statements come in and endowments and everything else are down 30 or more percent it's going to be very trying on balance sheets Any other member of the public that wishes to comment if not council barber could you call the roll Sure Yes Yes Yes Yes Yes Yes so let the record show it was a unanimous vote and again we're going to turn it back to you Patrick and I know you're going to walk through sustainability and sustainability at the end of the conversation I would be hopeful that we could not try to move forward this in an expeditious manner but rather continue to work on it at the staff level to come up with something that works for the hospitals and works for creating a truly good work product but again this is not something that I envision should be the number one priority for the hospitals in the next 30 days Patrick Thank you Mr. Chair before we get started I do want to give a shout out to Abigail Conley staff for guiding us through this entire meeting working remotely and from multiple separate locations and her ability to herd all of us cats is not unnoticed so thank you Abigail for allowing this meeting to go so smoothly so we're going to move into the standability plan we've been asked to weigh in on some of the public comments as a way of recognizing and clarifying some of the points that were raised after that Kirk having discussion just now would like to hear a little bit more from the board on the direction that this goes of course all of this so far has been done in a world that is kind of temporarily on hold right now so it is a matter of process to move through this and that's what we're going to do these three public comments from 226 to date the original presentation to 311 we bucketed the comments and do a general topic such as the financial framework and then process, scope and content some of the suggestions were that we use more Vermont specific benchmarks New England benchmark marks multi-year rolling trend analysis and a component regarding the service line so I'll start with that we brought the presentation forward on the 26th regarding the SMP benchmark that we were using those before 2018 they were released publicly in March of 2019 so just to clarify they weren't behind the payroll that was the result our paywall was the result of a Google search and to get as much information as possible we put one of our email addresses into the SMP global rankings website and unfortunately they send a ton of information but none of which we paid for should we decide to move forward in the future with the SMP benchmarks we're definitely going to want to explore having to pay for them so as of right now it's not behind the paywall it is accessible to anyone with an email address but in the future it will be if we want to keep up dated information we will have to pay for that regarding the financial metrics and discussion of operating metrics we really want to do it here to the regulatory nature of our work by keeping ourselves adhering to financial metrics as a measure to follow the progress of the sustainability plans from that perspective we have on the hospitals sustainability and financial bottom line balance sheet, income savings, etc because we regulate MPR growth and change in charges we didn't want to go too far outside of that into the operational side of things so therefore the financial metrics moving forward again we're going to be a measure of progress and a recognition of the starting point for this change and that's how we present it did not want to involve ourselves in the operational metrics because those metrics are set and measured by hospital leadership and staff would have a very hard time utilizing operational metrics hospital by hospital basis because they're very unique to each organization on a level that we would not have the resources to analyze so that again is why stuck with the financial metrics as a whole or as the director told their CEO accountable for operational goals and aims and the CEO hands that responsibility and accountability down through the organization to achieve those so we don't recommend utilizing any operate metrics in these plans moving forward however that could change but as of right now that's our recommendation as presented we believe the S&P metrics are appropriate and we know an example we do have flex monitoring critical access hospital metrics that we've used for several years and we would certainly be willing to incorporate those into the measurement for regarding sustainability the metrics from the S&P is being used to supplement the law of metrics that in the past we were deriving from an understanding that we no longer have access to that it seems they have suspended that publication and we needed to fill that void and the S&P what the means by which we're seeking to do that any other analysis regarding rolling averages or trend analysis would be incorporated we currently use that type of stuff in our regular hospital analysis on a monthly basis and with hospital budgets such as discussed today so just to the S&P we would incorporate current practices as well and that's a clarification on our end that we sought we needed to bring to the public forum today we do have confidence in those S&P figures we do recognize as well that there's no perfect metric or set of metrics that will be useful to the specifics of every healthcare organization during our CFO budget guide meetings we did ask the subset of things CFOs who they use to benchmark themselves again and all stated they they do use S&P global rankings benchmarking so we do have confidence that those are good figures to use and good benchmarking marking that we can use moving forward in ability and other applicable processes that we have we are going to become more specific around those in the coming months we are going to be getting to ask our hospitals to benchmark themselves for example the S&P does break it down into stand on hospital and do they fall in the A rated range B rated range what have you so that we know exactly where these hospitals are benchmarking themselves with the S&P we also recognize that Vermont is under a separate regulatory framework but if that's not the only factor impacting our hospitals from a focal perspective and we don't want to be short-sighted in limiting our benchmarking because of that loan item hospitals in Vermont are facing similar challenges and opportunities at hospitals around the nation and we feel the S&P's information takes that into consideration so we do recommend we continue that as at least one financial measuring tool and we are open to adopting their ones as well so that's our verification and recognition around the finance and operational piece the process scope and content bucket we do recommend some more input from the stakeholders hospitals specifically or if we can more centrally work through Vaas and Jeff's team and his team as far as building that framework out furthermore we do recommend that sustainability term probably does need to be defined more so so that those who are charged with delivering the plan have a clear understanding of that definition as preparation of those plans commence whatever the timeframe for that be moving forward we also recommend that the goals be better defined overall but also that each hospital should be allowed and expected to outline their unique and specific goals from all of our there is a one-size-fits-all around this and as we've stated they're facing unique challenges but they're also facing challenges together as well and in the context of today's discussion I think that's become more apparent than ever we have spoken to the Vermont office of rural health regarding the resource intensive nature of this type of ask from our hospital and we've spoken with John Olson and provided some feedback on potential funding that may be available to help consult on this topic and we recommend making use of both of his resources and his extensive contacts nationwide regarding folks that he knows have worked on similar projects such as this and finally in time the process should probably be expanded to all of the hospitals but until we get a framework in place understand the work involved we would recommend that we stick to the original sick hospitals and once we establish that then we recommend the board expand the order to the entire hospital system as was commended by one public comment so we want to be conscious of the fact that we do this right on a smaller scale and then open it up from there because it really is a system impact type of scenario that we're looking at now so we did want to say that with the plan as presented it is a step in the right direction we are moving towards creating a sustainability framework to Kevin's point there is a little bit more that we do need to do on our end from a staff perspective but we wanted to recognize the public comments and clarify where it is Okay questions from the board Are they still there? I'm still there here is Robin I think Kevin to your earlier comment the reason we started this in the first place is because we were concerned about ensuring the sustainability of our healthcare system and it was an endeavor in a different environment given where we are now I think doing some more work internally with staff and trying to figure out how to get additional stakeholder engagement when it's appropriate makes sense but I agree with your opening comment and I quite frankly agree with what Justice said earlier that sustainability planning is going to be even more essential after we move through and see the results of the emergency but trying to figure out how to do that in a way that works with today's environment is what I feel like we need to focus on now other comments from the board I agree it's one of the board members who is pushing heavily to have the sustainability plan but I still agree that the timing has to be right in terms of the resources that the hospitals are going to need to devote to this and I think if we can work internally among our staff to tighten this up and think about what they should look like and look for external consultants that would be able to do this work consistently across the hospitals that would be ideal so I would look forward to having those kinds of conversations about this and I think it would be a great opportunity for us to have the resources to help the hospitals one of the public comments was about the time and the resource intensity of this exercise so to the degree that we can have conversations about resource availability to reduce the burden on the hospitals improve the consistency of the analysis and I still do think this analysis is going to be even more important when we come out of this but we have to respect what the hospitals are trying to do now with respect to public health crisis other comments from the board if not does anyone from the public wish to comment on sustainability hi this is Eric Schultz from the HCA I agree with everything the board has said our office continues to have skepticism about the usefulness of the S&P indicators you know I presumably we are going to be using these indicators moving forward in the future as Patrick said future years are going to be behind the pay wall it's kind of irrelevant the most recent data can be crazily found with difficulty I think the issue of having Vermont hospitals as a group all being in the most vulnerable category probably isn't going to help develop policy interventions that are context sensitive and you know our comments stand regarding the other essential health services I had emailed Elena some folks at UVM who have looked at transportation access to healthcare services specifically in Vermont they're based in UVM they've published a few articles appear to be transportation planners so perhaps they would be a useful person to talk to about the aspects of sustainability planning that probably is going to be too much of a burden on the hospitals thank you thank you are other members of the public this is Devin Green from the Vermont Association of Hospitals and Health Systems and again appreciate the board looking at the sustainability of our hospitals and also appreciate that they recognize that at this time hospitals really need to put all their efforts on COVID-19 and it's very unclear what things will look like afterwards so as much internal process that can happen that can also simplify the process and put out the process until we're out of COVID-19 would be helpful thank you any other member of the public hearing none question for general counsel Barbara I don't believe we truly need a motion to have the staff keep trying to fine tune and find funding sources or other resources that could help in this but given the fact that it was part of budget orders is there a motion that would have to be offered at this time or not I think we should take that back and talk about it I mean without changing the budget orders and what's coming to mind is the board could just not enforce that and kind of pursue this as the new direction but I think we should we should probably think about that and I don't see a need to decide that today so okay so unless a board member finds a pressing need to make a motion I think that we are done with sustainability discussion at this point is there any old business to come before the board hearing none is there any new business to come before the board yeah I'm sorry this is Howard from VPR I'm wondering if you could just clarify that last sustainability conversation I'm not quite sure what happened at the end there what happened at the end is that the staff is going to continue to work at fine tuning what is a best practice for a sustainability plan that will actually yield good results for the hospitals and the future success of the hospitals but at this point we are not proceeding and expecting hospitals to do anything on sustainability in the short term given the focus on dealing with COVID-19 and so we will continue to look for a funding source for outside resources to be of assistance when it is the proper time to go forward but at this point in time it is not the best use of hospitals resources given what they're facing today is there any new business to come before the board so before I ask for a motion to adjourn I just want to thank everyone I didn't get much sleep last night worrying about how we were ever going to pull this off technologically and making sure that we committed to having public comment and abiding by the open meeting law and so many people have worked behind the scenes to make this happen and just truly amazed that we didn't have a technical glitch because I thought for sure halfway through I was going to lose everyone and that I would be sitting here in a conference room wondering what to do so I wish to thank everyone involved especially Abigail and the finance team here Janine and Jean for really making sure that we had the technological capabilities to pull this off so with that is there a motion to adjourn so moved second it's been moved in second and unfortunately I think we will have to do a roll call on that one as well Mike Barber that's correct was changed the order of this time member Pellin yes member Yusufer yes member Lunge yes have a great rest of the afternoon everyone remember to keep safe and keep your social distances and we look forward to a time where we're all back in the same room together


So here's the thing, it is January 2nd, but I live in Florida. I'm a silhouette now, and I'm at the beach. That's something you can do when you live in Florida, even though I'm not a huge beach person. But before I came to the beach, I had a little bit of time. I was actually finishing up, or not finishing up, but working on some of the Android videos, which you guys probably have already watched, because you're going to see this video much later in the future, but I want to record it now. So I have an upcoming series on C programming, and the thing here is C programming is not my best language. I know it's just enough to get by, so I've kind of avoided doing tutorials on it in the past. But I thought it was about time that I did it, you know, just bit the bullet and did some C programming. The thing is, it's a lower level language, I find it easy to use, but there's also people who program in C tend to be very particular about how things are done, and it makes sense, because with a lower level language, the lower you get, the more likely you are to get bugs that can cause security flaws. So what I'm asking of you guys, when you watch these, if you are familiar with C, and you think there's a better or safer way of me doing something I do in the video, let me know. Nicely in the comments. So yeah, I'm going to go over that for the next couple of weeks, month or two probably, and towards the end of the series, we will look at also cross compiling, compiling your code on Linux for Windows, and then also probably embedding icons into those applications for Windows. You don't do that on Linux, which I'll talk about more in future, because there's no need to. Well, we'll talk about more in those videos. So I thank you for watching again. Let me know what you think in the comments of the videos that I create, but be nice. And yeah, I hope that you have a great day. Visit filmsbychrist.com. That's Chris McKay. There's a link in the description, and I hope that you have a great day. Bye. Bye.


In this section, I will be telling you about the efficient market hypothesis, which is abbreviated as EMH. It is basically an application of rational expectations and that it helps us in explaining how the prices of the stocks and other securities are determined. This particular theory was developed on the basis of the PhD dissertation of Eugene Farmer that was submitted in 1960s. So, basically it tells us about the determination of the prices of the stocks and other securities. And it also, it is basically assumed on the basic principle that whatever information is available pertaining to any stock or any security that is equally available for all the different types of individuals that who are participating in a market, in a financial market. So, the level of information is the same among all the participants of the financial market and that information is basically reflected in terms of the prices of the stocks or the securities. So, in other words, if we want to determine the value of the return according to efficient market hypothesis, it can be given by the formula which you can see right now. It is basically the difference between the future price of that particular security minus the current price of the security. And then we add the cash payments that are expected or that we are going to get from that particular security in the form of dividends or any other payments. So, here the capital R is the rate of return on the time of security which is being held from the time period t to t plus one. So, Pt plus one is the price of the security at time t plus one and Pt is obviously the time period, the price of the security at a prior time period, the reference time period from where we are trying to, the time period which we are considering as the base period. And then C stands for the cash payment and it can be dividends or any other cash payment that a person or an investor can get from time period t to t plus one. So, similarly, using the same formula, we can find out the expected returns. That means what what return I am expecting in future and for that purpose, I will be taking it into account in order to calculate the expected return. I will be taking into account the expected future price of that security. So, you can see that there is a little superscript of e at the top of Pt plus one. So, Pt plus one is the future price and when we put e at the top of it, it means that we are now talking about the future expected price. So, in order to calculate the expected return, we take into account the future expected price and then we subtract the current price or the prior time periods price and then obviously the cash payment will be added to it and the whole thing will be divided by Pt. So, this is how we get the return the expected return. So, efficient market hypothesis says that when we when we are talking about the equilibrium, it is essential that the optimal forecasted return that means that you have considered all the relevant information about a certain stock or security. And on the basis of how it is going to perform in future, you are going to find out the expected price in the future, the whatever possible cash payments are there and then we calculate the expected return. The expected return should be equivalent to the if we have we are having a certain value of the current return value, then we then the equilibrium situation can be obtained at a point where the optimal forecasted return return becomes equal to whatever return is there in the market. So, this is how we can establish the equilibrium level where simply we can put up that equilibrium rate is that rate where the optimal forecasted value becomes equivalent to the current returns value. Basically, it all it depends that the since people are very much clear about the level of information or the type of fluctuations or movements that are going to occur in the market pertaining to a certain stock. They consider all that information they utilize that information and then they accordingly decide for a certain optimal forecasted value of the return and that helps them in determining the equilibrium level of. Returns in the of a certain from that can be yield that can be earned from a certain stock or a security.