I get that you try to keep it as lean and mean and as efficient as possible. I get that, but is there an adjustment made or review or analysis of what for monitors can afford, even if it's not consistent with your efforts to get it as low as possible? We have in our budget which drives that number. We're looking at what can we do to decrease that number. When we put together our budgets, we look on first pass on what other adjustments can we make to those cost inflation assumptions. So the rate that you see today is not the first rate that you would have seen had we just submitted the budget on first pass. We went back through all of our adjustments trying to make the number as low as possible. Looking at what we were planning for salary increases, talking to our supply chain leaders to say, is there something that we can do about this cost inflation? Is there a way to offset it looking at lower cost alternatives that might have different inflation assumptions that tie to them? So we do go through that process from when we first generate a rolled up budget to what you see today. We're definitely thinking about affordability and trying to make that rate increase as low as possible. We're also at the same time trying to pursue other non-commercial rate increases. Those opportunities still exist out there to try to make the care that we're providing more affordable. We still think that there's a good chance that we can make those happen in future years. We couldn't get them across the finish line for this particular budget. Steve, I don't know if you want to add anything to that. Chair Foster, I'll start with health care is expensive and health care at tertiary academic medical center. Things that we do are amazing and I'm proud of them, but they cost a lot of money. Our jobs who are very best to have them cost the least possible, they possibly can for Vermonters. That's by providing high quality care, safe care, minimizing complications, and then comparing ourselves. We know from the Medicare benchmark data that we're in the bottom 25th percentile for costs for the care we deliver is expensive. We work every single day to make sure we deliver the most keeping it as low cost as we can. But labor costs are 61% of our budget. They're going up. Health care is a people business. We need to pay our people well to provide high quality care. The equipment we're using is expensive and we have a lot of other pressures right now that are making it even more expensive. Access right now we're paying people extra to catch up. We're keeping that extra operating room open by paying overtime and special pay. We're paying people on Saturdays to do mammograms, CT scans, MRIs to keep up to get caught back up. But I do want you to know that everything that we do, we benchmark ourselves, but we acknowledge health care is expensive and it's on all of us to work to keep it as low cost as we can while providing good access, safe, high quality care. The other thing that I would add, Chair Foster, just in terms of the affordability question and decision point that we made before we submitted this budget. I think we highlighted earlier on, I think Sonny had this in his comments at the beginning that we've incurred 90 million dollars more cost inflation than what we put in our FY23 and 22 budgets. That means that the commercial rate increase, the Medicare rate increase, and the Medicaid rate increase did not cover that cost inflation. When we put together the budget, there was discussion both in terms of that cost inflation that wasn't covered. Do we add an additional piece to our required rate increase to make up for the fact that we didn't, we undershot exactly how much our cost inflation was going to be this past year? We also had a discussion about the fact that we are significantly depleted from a cash reserve perspective, which means that we're falling behind in terms of capital investments. We had a discussion, do we add more to the rate increase to account for the fact that we have a significant amount of cost inflation that wasn't covered by rates and that we need more resources to take care of our modders? We decided not to do that. It was all due to the affordability question. What we've submitted in the budget is truly what we need to start to make some progress here on our finances and meeting the needs of our partially due to the volume of questions. If I interrupt you, that's why. Just yes or no, does the network look at how much money Vermonters have to pay for increased health insurance costs when it does its budgetary process? I'm not aware of a data source, if you will, that would tell us that in terms of what's available to pay, what Vermonters are available to pay. We know that there still is some subsidies that are going to continue in terms of the exchange programs. We keep tabs on that to see if that changes, but in terms of a number that you can point to in terms of what is available out there for Vermonters to pay, we're just not aware of any index or data source that's out there. Understood. Do you agree that the affordability of healthcare is one, important, and two, that the care board should be considering it in light of your budget requests? They certainly should be taking it into consideration in the budget requests, but in addition, one of the other needs that the Green Mountain Care Board needs to look after is the access to appropriate quality healthcare for Vermonters. That balance between financial sustainability, access to care, and affordability all has to be taken into consideration in terms of what you're looking at from our budget request. Yeah, agreed. Some of the public comment we received that happened with the VAAS request, it's happening with the budget process, is that non-hospitals like primary care, independent practices, mental health, physical therapy, long-term care, they're saying that their rates that they're getting from insurance companies are really, really small, if not non-existent as compared to UVMs and other hospitals. If we credit that assertion, and I guess I'm getting at is, should we consider that the system and what the system's getting in a rate when we determine your rate? I don't know if I can answer that question. Are you asking it in terms of is there other unregulated entities that you should be taking into consideration in the rates that they're receiving in terms of our rate request? Yeah, so you talked about access, but what I'm told, and the Board is frequently hearing, is that there's access issues because the independent primary care practice down the street can't afford to raise nursing salaries, and they can't afford to pay extra to have a nurse work on the weekends, and that's harming access. And so you discussed your access challenges and the need for rate to do that, to care for your community, appropriate point. My question is, should the care board be considering all the other providers in the system in considering your rate request? So I'm not sure how to quite answer that question, but I will say that certainly you can see very clearly that our decisions in terms of access have negatively impacted our financials. So whether it's a private practice physician group, a nursing home that's not connected to our network, any of those providers, if they don't have enough resources, they do restrict access. And it has a very direct impact on our organizations. But I don't know how to answer the question in terms of how you take a look at an unregulated entity and factor that into these deliberations here on our budget. Yeah, and that's what I'm struggling with. They say if we give you 13.5%, they're going to get left out and have a very difficult time getting rate. In fact, historically, they don't get rate if we give large increases to the hospitals. That's what they say. And so they can't provide the access to their community. And my question is, should I be cognizant of that and considering that and how much rate I give to the hospital? Because I get that the rate will be good for the hospital's access. My concern is it's not good for the rest of the system's access. Yeah, sorry, I can't give you anything to get something out of that. Is that actually true? We're frequently told that. And it looks like from the data we've seen that the hospital rate increases are historically significantly larger than non-hospitals. But I just wonder if they got a larger increase, if that would change their access or not? And do you have regulatory control over what they get or don't get? And is that like sort of out of scope of what we should be talking about? I'm not having a hard time just kind of figure that out. That's my question to you if you think that's appropriate. Clearly the top half of those with how our ability to provide access goes. And so I think there are going to be Vermonters that can afford to pay for and get care with private practitioners, etc. But I don't think that's what we're looking at. We're looking at can we provide access to everybody? And when we lay out what I see as our request, it is trying to do that. And so I don't know what to do with the private practitioner or the private group that is taking care of a subset of patients. But it's hard for me to, it's hard for us to opine on that. That's a different, it seems like a different group. Okay. It is a different group, but I take it your position is that the care board shouldn't, should be reviewing your budget and only your budget and your financial need and not the impact that they might have on the rest of the Vermont healthcare system that's trying to provide care as well. No, that's not what I said. I said that if we have knowledge about what that direct impact is and we should be really careful about that, about how they make decisions when we don't know, then it becomes really difficult for both of us from our end and from your end to be able to say, if we did this, this would what would happen to our private practice group that we don't really have vision into. I'll try and finish up here. Your budget request for fiscal year 23, the budgeted margin, how much was that? Was it 1.7, 2% something like that? Mark, do you have that? Hang on, Rick. I'm pulling it up right now. I had it in the narrative from last year, page 15, that's 1.7. Actually, the budget that's in the budget system, I have 2%. Okay. 2% or 39.3 million. And year to date, where is the University of Vermont Medical Center on margin? Let me get that right now. I have that too. The budget tool has it at 3%. Year to day actual through July, and I'm just making sure that I'm looking at the right hospital, the actual is 2.1% or 35.1 million through July. Just want to keep the, is it network and University of Vermont Medical Center? Just want to make sure that we're doing each of those correctly, right? Actually, I am only referring to University of Vermont Medical Center right now. So thank you. Okay. And you said there was $90 million of cost inflation in fiscal year 23 that wasn't budgeted for? 22 and 23. 22 and 23. Okay. And so notwithstanding that $90 million cost inflation, you're still at about what you had budgeted for your fiscal year 23 margin. Is that right? Correct. So you're able to absorb that 90 million, whatever part of it is in 23, without having to see your margin compress? Yeah, we have a fair amount of still one time dollars in the FY23 results. So we've received some FEMA dollars. We've received some catch up payments for GME, IGT arrangements. So there are some numbers in there that won't continue into FY24. But without those, obviously, the cost inflation overruns would have produced a much different result so far in FY23. When the care board made its 23 decision, it considered those in determining that the rate could be lower than the 19.9% requested, right? It did. At that point in time, we were looking at, I mean, we still are pursuing hospital directed payments as an opportunity for our network to reduce the future commercial rates. We talked about that. They haven't materialized, but it's still something that we're pursuing. Okay. So I want to bring up a topic that was addressed in your intro. I think, Dr. Epin, you said working with us, the care board and the medical center together on cost containment. And Mr. Vinci, you said something about the increase last year was very much appreciated. And it sounds like that increase, which was hard to do, to approve that kind of level. But after the board did it, it seems like the amount of money the care board gave in its rate-increased decision was not wrong. It seems appropriate. You had this 90 million unexpected cost. You had the GME money and the Medicare reimbursement change.  But after we make budget decisions that aren't consistent with what you submit, there's generally some fairly caustic language. And it's inconsistent with you saying you're trying to work together with us and saying that you appreciated it. There was some media the day of the decision, which I think called the care board's decision, at least implied that it was wrong or not based on anything. And Dr. Leffler, you sent a message to UVM employees where you said, quote, the care board approved a smaller amount of 14.77. How that arrived at this number is unclear. We work in an evidence-based mission-driven field. And so strongly believe that this type of dartboard decision-making doesn't help our patients, our community, or healthcare across the state of Vermont. I wasn't involved in that decision, but looking at the data now, it looks to me like that decision improved affordability for Vermonters and UVM still hit its margin. Are we going to see this kind of rhetoric if the care board doesn't provide the kind of rate request you're seeking this year? So I won't speak to the rhetoric that was produced last year, Chair Foster, but I can tell you what we're looking for through this process is whatever the decision is, that it truly is based on data and facts. I feel like we've provided all the data in excruciating detail to help you all make for the board to make their decision. We did talk about the impacts that we could see in terms of rate relief, which did factor in into the lower rate. Certainly, we did not know at the time that we could pursue FEMA dollars. Obviously, we knew that it was still a possibility, but we had to significantly scramble to find ways to offset the fact that the commercial rate came down. And the rationale behind it was a little bit harder to understand. What we're looking for this year is the decision that's made. If it's made based on the data that you see and that you're basing it on the facts that we've presented, the facts that you have available to the board that we'll have to take a look and see exactly what impact that has. I think we're going to talk about that in executive session. But I share with you that the budget that we have submitted without knowing what other dollars may be available next year, this is what we need. And I think you can see in our financial metrics, we're still going to be struggling financially next year. The projections that we've made for the impact this will have on our cash reserves to reinvest in the organization. We're not making a huge leap in just one year. This is going to take time to rebuild. And so that's what I would share with you. Chair Foster, since you called me out, I'd like to be able to respond. The budget that we submitted for our 23 budget took hundreds of hours to put together. And when we brought the budget to the Green Mountain Care Board, it was our very best estimate of what we thought it was going to cost to provide high-quality care to our monitors for fiscal 23. There were things that we were unsure of when we submitted the budget that we're very grateful did come to pass, even dollars and other things. But what you're talking about, the email I sent was an internal email to staff. And my specific comment was as we presented our budget, the hearing, there were people in the meeting back and forth in real time on the public session determining kind of a middle ground, like, well, I want to cut it by this much. We should cut it by that much. Let's meet in the middle. That felt to me not fact-based compared to the work we put in. After the budget was approved and the other dollars came in, we've worked unbelievably hard at the medical center this year, every all 8,000 people here to turn us around. We lost $24 million in fiscal 22. And we have a positive margin this year. That took intense hard work. So I do want to say that we are grateful for the dollars that came in last year and the budget that we got. It was a specific comment around the budget that we built and how it felt like in front of the public, there was a back and forth about what the rate was going to be and how you met in the middle. I understand that. I think that's a fair observation. As you know, we don't have an option to discuss this with board members outside of public view. But, you know, I've negotiated a number of things and it seems like it's kind of typical for people to have different views and to kind of coalesce around a particular area, kind of accommodating people's different views. And I imagine that happens with your budget. Mr. Vincent said there's a number of iterations and you went back and forth, right? I mean, your number, when you give it to us, it's not some sacrosanct thing. You said it's your best guess. So, did you have back and forth when you came up with your budget and then kind of all came to an agreement? Yes, I think you're right. But I do think when you look back on the first thing about the 90 million, if you remember the 90 million, isn't just UVMMCs. It's also split between UVMMC and CVMC. But when we're trying to make a budget, when we get whatever dollars are given to us, there are things that you're not noticing that are happening behind the scenes that we're not doing in order to get to that point. And that's what's really hard. So, the way that our repairs happen behind the scenes is based on the dollars that are coming in. And so, are we going to fix that elevator proactively or are we going to wait till it breaks? Do we have enough? We know it's going to break sometime this year. Do we want to wait or do we want to proactively do it? Do we want to go ahead and buy Epic for home health and hospice? Because that would make the ease of care for our patients moving from our hospitals into home health and back so that the documentation can go flow seamlessly like the rest of the system. Can we afford to do that or not? So, there's a lot of decisions that are happening that are truly for patient care that don't happen when we don't have the dollars. That's the hard part of being able to kind of visually see what's going on. So, when you say you didn't get what we asked for, it becomes really tough because when we make decisions that impact patient care, it makes it a lot harder to recruit doctors when we have a decreased amount of dollars that are coming in. It's a lot harder to reward doctors for the work that they're doing when we know we can't have enough. That has an impact on the future years. All of those things that we're putting into play very transparently.  That's the challenge that we have. So, you can give us whatever we ask you for what we really think is a reasonable adjustment for what we need, which has already gone through a bunch of compromises. Lots of people are arguing that it should be more. Some people are arguing that it should be less, just like what you're seeing. And we're thinking about all of those factors when we put it into place. But there's no doubt that if there are changes to what we've asked for, that we make changes in what we can do. It's pretty straightforward. It isn't and it's transparent because everyone can see what we're doing. Totally, totally right. I think that's exactly a great point. I think it's true. If we don't give you as much money, you're going to have to make hard decisions and that's what we're trying to balance is what are the consequences to that and what are the consequences of giving the increases that are requested. So, Dr. Eponite, I think you're spot on. It makes hard decisions and you could do more if you got more. But I appreciate your opening remarks about understanding what we're trying to do. Just a couple quick ones here and I apologize for my care board members. We can go late if we need to. But on this point of you obtaining more money to help with access to care, do you think that the high cost of care is a significant barrier to health care? Yes. If care costs less, we could do more. And so, is that a situation that we should be considering in connection with this budget, that the high cost of care can be a significant barrier to health care? If you could control the cost of care. So, if you could control the biggest part of our cost of care, which is our people, if you could reduce the cost of nurses, if you could reduce the cost of doctors, that would really help us. If you just simply give us less money in that fixed environment, that doesn't help us. Right. But what I'm getting is the healthcare advocate talks sometimes about how we're losing access because people can't afford health care. And is that something I should be balancing in our budget decisions? So, the cost of health care is impacting people's access. You want money to improve access, but is there a downside to that of blocking access because of the financial decision? I think that's the balance. That's the delicate balance that we're walking. Unless we can figure out a different way of, I mean, and we can talk about this, this might be out of scope, but talk about, is there a different way that our system can pay for health care? Can we use the Vermont provider tax in a different way so that it supports people that are having trouble paying for their insurance? Can we use the wealthy folks who don't collect an income but have lots of money? Can we tax their wealth in a way that would help support the rest of Vermonters who can't afford it? There's lots of different ways to do it. I don't think reducing how much you're paying us is necessarily the way to do it. That's the balance. You can't have all of it. Care costs this much.  If you reduce how much we get, we reduce how much we can do. We're trying to be as efficient as possible. We want to be as efficient as possible when we deliver care. I don't doubt that for a second. I'll just add that right now, we have significant backlogs. People are right now seeking care and paying for it and affording it. To this point, what we see right now in Vermont is there are access challenges. We've heard about them before.  We're doing every single thing in our power to improve access while keeping it as affordable as possible. Some people are accessing plenty of care. I want to read you a couple quotes just to set the framework of what I'm seeing here. In 2018, your former CEO said that, quote, the high cost continues to be a significant barrier to healthcare. This situation is unacceptable. He also said, I see many patients who went without treatment because they simply cannot afford care. That has to change. It's those points and the fact that that's five years ago and healthcare in Vermont has gone up significantly. If it was unacceptable back then and there were patients avoiding treatment, I think that's something that we should be thinking about. Maybe in your future budgets, we can ask for it in our guidance, but it seems like there is an access problem back then that was unacceptable because of cost there is today too. I'm just flagging that as something that we have a responsibility as regulators to consider. There are many people waiting to get into your hospitals for sure, but there are some people who are not because they can't pay for it. Yeah, I think I get apart from me to speak for what John was saying, but I think when we talk about it, when I talk about it on a large scale, I would say the same thing. It's a national problem though, not a local problem when we talk about that, that we have an issue with the way that healthcare is being delivered in America. We're doing a phenomenal job in Vermont compared to most places. I think you've got to keep it in context of where we are, and I think you're right. We know that there are people that don't get the care that they want or deserve because they can't afford it, but we have an amazing system that delivers care to everyone and we're committed to doing that equitably. The people that often leave our system because they can't get access to doing it are the people that have a lot of money. They can go elsewhere to get care. They can pay for it with private practitioners that only take certain insurances, etc. We don't do that. Our job is to have a different model of what we're trying to do. So when you reduce, when we have executive compensation, I understand that the justification is that they're benchmarking this is the amount of money that's needed. Yes or no? Will you provide the board those benchmarks? I'm trying to remember. I think this is something that we can share, I believe, in executive session, but I'll look to Eric and Sonny to validate that. As with any data regarding competitively sensitive decisions like how much to pay versus doctors, executives, we can provide you with information regarding what is taken account in making those decisions to a degree and to that degree, we can talk about it in executive session. Would you provide the benchmarks that were used to set the executive salaries confidentially to us? We can talk about that in executive session and I can talk about it with your legal team to ensure that that would be possible. So I don't think whether or not you'll provide the documents is confidential information, so I think you can answer if you'll provide us the documents. We'll talk about it in executive session and with your counsel. Okay, well it's your burden to justify your budget and I think looking at the benchmarks would assist us in validating that. We understand our burden and we understand the criteria by which the board is required to judge our budgets. In terms of executive compensation, when you have the incentive compensation, do you have any review or consideration of UVM's ability to control operating expenses? I'm getting at the factors that are looked at in terms of setting executive compensation and maybe this is a question for the chair of the board, but do you consider UVM's ability to control its operating expenses in determining whether or not there should be incentive comp awarded? I guess I could probably comment. I don't know if Allie wants to comment or if she was waiting for executive session to comment. Go ahead, Sunny. Yeah, I was going to say certainly a biggest part of whether or not executive bonuses get paid is based on whether or not you hit your financial margin. So if you say that it would be virtually impossible for us to hit our financial margins unless we are operating as efficiently as possible. And so in the past number of years, and this will be another year, we will not be able to make a margin. And so the biggest part and sometimes the only part of the bonuses have not been paid and they will not be paid again this year. So does that answer your question? Yes, says the answer. Well, kind of, because you can hit your margin if you have extremely high rate increases. I'm talking about operating expenses. Is there like a review of operating? So some of the things we're trying to achieve as a state is affordability, right, and access. And we have, we're paying as a system, you know, what I consider significant sums of money to executives and healthcare systems at UVM in particular. And we want to ensure we have this stable of thoroughbred talent, right, that we're paying for, and is it being properly incentivized to achieve what the state wants? Is there any opportunity to ensure that this team of leadership is incentivized in the way that's consistent with what we want as a state, which is lowering costs, improving access, delaying weight, or sorry, improving wait times? Are those things, is there an opportunity there to align the state goals with how the incentive comp is awarded? So we have a complex compensation committee that looks at this our voluntary board. And I think, again, I'm not sure if Ali's going to comment now or later on about the process of what they go through. I can tell you it's having gone through it once now and seen it. It is rigorous. They really hold the executives accountable. And they're about the patient's experience and their accessibility. The costs are funny. You have to be careful about what you're going after when you go after costs. You could decrease costs, right, that's why margin is a good number there. But there are many, many of these. So some of the things that we talk about are we have tangible measures of the employee experience that we're looking at for this year. And that's done by a Gallup survey that's put out. And every executive, every hospital partner president has a goal that is to improve their employee experience because we know that's going to connect to the way we have access. Patient experience, similarly, every hospital partner, including me, has the same thing. Our hospital patient experience has to be improved by a tangible measure as measured by prescaining. The margin is a part of that as well. And then every one of the shared services has a benchmark that they have to reach to be able to do it. So for HR, it could be our turnover rate. Is our turnover rate getting better? Are we able to recruit faster? Whatever every one of the executives in those areas has a very tangible, specific piece. I don't know, Eric, again, if I'm happy to at the end of our talk, let me let me let me interrupt you. The whole thing with you. Yeah, I'm happy to share the whole thing with you if that's okay. Yeah, yeah, just if you can if you're willing to send it to us. That's great. And I'll just put in a plug that ensuring that alignment is beneficial and we can we can move on. I'd heard and read somewhere that UVM executives had taken pay cuts or for gone bonuses or some variety of that during COVID. And I was wondering, you know, I get everyone's mission driven and talented and, you know, you have a high market value. I get that. But given the affordability challenges we're having, is that an appropriate thing to happen here this year or next year to lower some of these executive costs? And I know that's not going to solve the problem. I know that doesn't solve affordability. But for people paying it, it is hard for them to see these $2,900, you know, those kinds of salaries are very high in Vermont. And I wonder if that's something you don't have to answer it. I'll just put it out there that perhaps that's something that could be considered due to the affordability challenge. I lodged you for doing it during COVID. And I'll just put a plug in that perhaps that's something that should be visited. I know I'm not trying to take away your money at all. I get it. You worked hard, your top notch people. But there's a lot of top notch people working really hard to pay this. And it's hard for them to see that kind of number. So I'll just leave it at that. The only other quick thing is there was a Digger article back in 2017 discussing several private flights that UVM Medical Center had chartered to investigate the acquisitions of the New York hospitals. Can you tell me when the last time UVM, any UVM entity, the health ventures, the captive, any time a UVM entity last chartered a private flight? Well, I can certainly say that it hasn't happened since I've been here that I'm aware of and certainly I have not been on one. I don't know if anyone else is aware. I just encourage anyone to speak freely if they're aware of it. I'm not aware of any since 17, definitely not since 19, since I've been president. Great. And I'm asking these because of the financial challenges people are having. But is first class travel permitted for anyone who's traveling, is being paid by any UVM entity? I can say that. I think we have very strict guidelines on it. I think for international travel, for business, I think we are a loud business class. But I'm not sure if I see some HR person. I can give you the, I'm happy to share those regulations with you, Owen, that we have across the network around our travel guidelines. They're open and transparent and everyone knows about them. Great. Yeah. If you can send them, and again, I'll put in a plug that just for people paying these rates, some austerity measures and enforcement of that would be, I think, a good optics and helpful for people, not just good optics. I think it's the right thing to do, given where we are as a healthcare system. And I know you guys recognize that. So, so thank you. I have nothing else. Thank you all very much for answering my questions. I apologize for taking so long. Hey, great. Dave Marmin, I don't know if anybody needs to take a few minute break. It's been a while since the last one. I'm okay going on. Rick, do you need anybody? Okay. I just want to pick up a few things with Chair Foster left off with regarding executive compensation bonuses. Dr. Eppen, you mentioned there was a margin target that had a large component. It sounds like you're actually making a margin in FY23 as of now and projected to make one. Would that not count? No, it was a, it was a, correct me again if I'm wrong. I wasn't here when it was done, but you have to make the margin that was actually there for the network to hit that target for everyone. And we will not make it this year. We will not hit that target. It was, it's not a, if you hit 20% of it, you get 20% of it. You had to hit the margin actually. It's a binary threshold. Okay. Yeah. But so just a few, I had some, a bunch of questions that I had sort of wanted to ask you, but then there's a few things that came up, which I don't want to like go too extensively into, but just a few things, a follow up question from Chair Foster regarding the FY23 actuals. When, when during the year does the, does the rate increase related to the board's order come into effect? So the vast majority of the, the rate increase comes into effect in January. Most of our, most of our commercial contracts are January. Some of the, some of the Medicare rate increases come into effect in October. So a small portion happens there, but the bulk of the rate increases happen on January 1st. Okay. And if, if you were to, and when was the FEMA and GME money? When did that come in? We'll have to get back to you on the exact months, but it was, so the GME money was definitely in June. That's when the retroactive payment was made for last fiscal year. The FEMA dollars, I believe, were in the February, March time frame somewhere in there. Okay. Because looking at January on, and I actually don't have it up in front of me right now, the margin each month. Do you know what the margin would be if you just include? Yeah, but there's no doubt that January was the, was the turning point. So the, the rates taking in, coming into effect in January, plus all of the, the additional work that we've done improve access, reduce costs. One of the things that we highlighted in our, in our narrative is that we, we were significantly under budget on administrative shared service costs so far this year, somewhere in the $20 million range. So all of those impacts really started to, to take place and started to happen in the January time frame. The, the actual margin without the FEMA dollars, Dr. Merman will have to, we'll have to, we'll have to get back to you. So Dr. Merman, one thing to take into account is that many of our costs go up October 1st. So new contracts for employees, the, the union wage changes, cost of living increases all kick in October 1st this year as well. And so you don't cover those, those costs until the commercial rate kicks in in January. Same with, with 23's budget. Our expenses went up significantly in October 1st of 23. And then when the commercial rate kicked in in January, that helped overcome those cost increases for labor and other issues. Okay. And that's a cycle that occurs annually. Yes. But it, it would seem to be more predictive of, of where your revenue would lie at least, I mean, maybe, maybe margin because of those increased costs would be challenging, but at least revenue to look at once the rate increase kicked in in January. So from January to now, we build our rate increase based on nine months of the new rate. That's how we do it. We build that into the budget. Yes, we built it in in kind of a pathway of when we thought dollars were going to come in. Dr. Merman, in addition, you were asking about FEMA dollars and certain things that have been one time or initiatives we have taken on. So it's not just been the rate. We also impacted our wage index by taking the rural wage index. We apply for self-community hospitals. So we have been looking for ways to augment and supplement the, the rate increase. So it's a number of factors in addition to the FEMA as well. We've worked very hard on applying for every opportunity for funding that we could. Yeah. Actually, that brings up a point that, Rick, Dr. Vincent, sorry, had mentioned earlier on that I wanted to follow up on. Sorry. You had said there was other opportunities to potentially improve governmental reimbursements. What are some of those opportunities? The biggest one is hospital directed payments, which I think we discussed a little bit with the, the board last, last year during the budget process. What that is is for academic medical centers, similar to the GME program, to reflect the fact that academic medical centers take care of much more acute patients. They typically serve as the safety net hospital for their, their region. Medicare recognize or Medicaid, if you will, federal Medicaid, if you will, recognizes the fact that, that academic medical centers require additional resources. And the, the math behind those funds is it takes the hospital very, very kind of high level. There's a lot more detail behind this, but just very, very high level takes the Medicaid revenue that you generate on your hospital billings and brings them up to the commercial rates. So it reflects the fact that you need more resources to take care of the patients that you're taking care of, and also the fact that you're, you're training future providers that are, that will help the healthcare industry to meet the access needs. But you need a, just like the GME program, you need a, you need a partner in doing that, which we obviously have a very good partner with UVM to pursue these types of opportunities. So we're still pursuing it, but it hasn't yet, we haven't yet crossed the finish line with that, with that pursuit. Okay. I guess this is a little bit of a segue from prior comments, which I just wanted to ask if any of you were able to partake in the series of board meetings we had in the spring on cost shifting. I did not participate. I don't know if anybody else in the call was there. No. So I listened in on one of them, David. I was on the the Medicare rate. I think was it in Montana or Wyoming? I can't remember. That guy, I did listen to his or watch it. Marilyn Blankin on her last name, who was wonderful for Montana. Yeah. Montana. I was wondering if you had any reflections. Her presentation was a little bit less specific, I think, on trying to understand the impacts that go, the elements of cost shifting or revenue shifting. But I was wondering if you had any reflections on that and how you approach cost shifting and what you learned from that presentation. Yeah. I can't speak specific. Oh, good. I was going to say, I got to go back and review my notes. I wasn't expecting it. But, you know, David, I think just broadly, sorry, didn't mean to cut your offering and I'll let you answer it. Just broadly, I think it's really different when you're an organization where the goal is, I want to try to provide equitable, high quality care to everyone that walks in the door and that if we see a need, regardless of whether it gets reimbursed, that we want to then provide that care, it's really different when you take, when you have that kind of a situation and that kind of a commitment versus, you know, you could have an academic medical center that picks and chooses what they want to do and can deliberately make decisions about not covering certain things. And it's subtle, and I'm just going to give you the example, right, is that if you don't have psychiatrists, you can't provide mental health care. And so you can, you can, and you know this, you're in the emergency room, you got to take everyone that comes in, but there's no place to put them. And so people realize and learn where they can go and where they can't go to do that when you're in a system that looks at those kinds of things. We're in a system that our goal is, how do we take care of everyone? How do we take care of the needs of our community? And so we look at it really differently. We look at, we look at it, we do look at what makes money and what brings dollars in only for the purpose that we can then take those dollars and put it into areas that we know we can't make money yet we have to provide the service. And so it's a really different way to look at how to deliver care. And so when I think, when I was listening to the woman from that was talking about Montana, I think you have to look at it in the context of all the other hospitals and what were they doing? Did they shift the kinds of providers that they had because of what they were going to deliver or not? When you saw, I saw that I think if I remember right, there were like some hospitals that had higher costs, but didn't really provide information about what they were doing and what they weren't doing with the kinds of care that they were providing. So it was, it was interesting. But yeah, I don't want to, I don't want to comment down that road. Sorry, Rick, I didn't want to interrupt you. I think what I would say, Dr. Merman, is so again, so I apologize I didn't participate in that in that session. But I think this is where we've been incredibly transparent with the cost shift the last many years. We've included in our materials an exhibit for each hospital clearly showing the cost inflation that we're projecting for this current year. From there, we show very clearly the Medicare and Medicaid rate increases that we're projecting and then what the required commercial rate needs to be to cover that cost inflation. That I think that level of transparency, I'm not sure you would find in other regulatory processes, if you will, like we have here in Vermont that we're very, very clear and we show the exact figures and the exact cost shift every year when we submit our budgets. So I would encourage you to listen to the, especially the other two presentations, although hers was quite interesting regarding cost shifting. And they do comment a lot on sort of the concept of cost shifting, which some people say the cost shift doesn't exist. I don't think that's accurate. I think that what they're trying to say is that the cost shift is more of a relationship to market power than it is a necessity that I think an example was used once when there was a cardiac stent that Medicare doesn't cover the increased costs of the cardiac stents. We shift that cost to commercial payers. And then these speakers would argue that that's because of market power and that hospitals that don't have market power and all the hospitals I've ever worked at, Dr. Eppen, I've been very fortunate in this. See, everybody comes through the door and takes care of them. And if they can't have been fortunate to work in a place where I can transfer them to a hospital who's more than willing to take them regardless of their ability to pay, but that these hospitals, some hospitals don't have the market power and thus can't negotiate for high rates. Now we have a different system here in Vermont. And so therefore they are lower costs. Their costs are closer to the Medicare allowable costs, but their quality remains the same. And so I think it actually really speaks to what you guys did last year. You didn't get as much money through the rate as you wanted. You scrambled to find money. You worked really hard to reduce costs. And in the end, you've made a 2% margin and done quite well improving access to care, decreasing reliance on travelers, all the great work that you've done. So I think it's a really interesting concept. I would really encourage you to listen through those sessions and try to figure out how to think about how to integrate those into your budgetary process and your philosophy as you approach it. Yeah, I think it's just a really good point. Yeah, go ahead, Rick. I know maybe just to make one comment. I think part of that is what is what Sonny shared is those organizations may very well be deciding to not hire that psychiatrist, to not keep beds open because they don't have the capacity in the post-acute system to manage the flow of patients. So I think the decisions that organizations are making to get to those, to get to the financial targets that they need, if they haven't been able to truly cover the costs that they're incurring, I think it's important to understand because I think we've been very clear that we haven't made those choices. And again, we've been very transparent with what that cost shift means for us. Sorry, Sonny. Yeah, and I was just going to add just what Rick was saying before you responded. First of all, the Medicare cost reports, I'd have to really understand the consistency of how those are reported, just like we heard about the cost reports. If you don't understand what goes into it, is it part of a system? Is it a standalone? Is it a largely Medicare-driven hospital? That'd be a really important thing. The other part is on things like provider tax. Where does the Medicare dollars go in that particular state? Are they using it comparable to how we're using it to provider taxes go right back into taking care of the patients? Or do they go into housing and food insecurity, et cetera? Those are important. But the other part to remember, I mean, I would just not buy the stent if I couldn't afford it. If I thought that was the best stent, but I can't afford it, because I'm going to go broke, I'll use the second tier stent to do that. And so, it's like those kinds of decisions that are challenging. And here's the really big important part though. If it's you and me, and we know that Dartmouth has a better stent because either the clot rate is lower or the longevity is higher, but we're not using it here, the people that can afford it will go over and get that. And what we're trying to do is, we don't care who your insurer is. We don't care if you can pay out of pocket or not. We're going to give you the same highest quality stent possible. That's what we want to do. And those are the subtleties that you won't catch in the differences, right? That we have to be really careful about. I would really encourage you to watch these and read the body literature on this. I would say that the argument that we made by those folks would be that the stent price goes up, Medicare doesn't cover that increased cost of the stent. So now you have a lower margin operation. So the way you manage your lower margin operation could be to increase your volume. And you have lower margin per patient. And then you actually increase access and do more. It's just an option as opposed to just passing the cost directly on to the commercial insurer. It doesn't work like that. It doesn't work like that. We try to do as much volume as we can when we have the need. And so it doesn't work like the only way you can drive that is either you have to take the lower margin and we do less of what we don't have a margin on. Just imagine if you're the cardiologist and we tell you, listen, we're going to use this new stent. It's great, but you're going to have to do twice as many in the same amount of time. That's how we're going to make up for your margin, for your dollars. Just imagine if you're the doc or whoever you are in that provider. It's a scenario that doesn't work in reality unless you're going to compensate people differently for those kinds of things. And we've worked really hard on equity as you know on the compensation side as well. That's really, really important to us. Yeah, I wouldn't want the interventional cardiologist to hunt me down and say, Dr. Merman just suggested I do twice as many caths for a week for the same compensation. It clearly requires upstaffing in that resource too. But I would encourage you to listen through it and look at it. There's a pretty extensive body literature, especially over the last five or six years that really calls into question the necessity and it's more related to market effects. There's one thing I want to talk through. Sarah, is there a way you can put up page 38 of the narrative? One moment, please. Yeah, it's the, since this analysis of page 37, 38 of the submission discussing this sort of complicated financial and quality impacts of the inability to transfer patients to post-acute care or other appropriate care settings. I mean this is, you know, we've asked all hospitals to submit information on this. This is something that, you know, as a clinician I've known about for a long period of time is this is a huge challenge for healthcare organizations to manage or struggle to manage the impacts of transferring patients out of the hospital who need post-acute care. So I just wanted to make sure I understand the, this analysis clearly. So it looks to me that what you guys did here, and I'm just going to, you know, for specific concerns, I'm going to only look at the UVM MC and discuss the UVM MC component of this. But what we have here in the first column is the actual average length of stay, which I assume you use a similar statistical method to the vizient of taking, you know, sort of a more, more complicated geometric mean or whatnot. But this is the average, average length of stay of patients admitted to UVM. And the vizient is a matched group. It sounds like they're matched by demographics. They're matched by DRG groups. So meaning their diagnosis related groups from other organizations throughout the country, I would assume peer patients elsewhere. Is that right? And so, and so vizient looks at these, this peer group and says, okay, well, we would expect UVM MC that your patients would have the same length of stay. And so the next column is your actual daily census.  And then the difference between those two numbers multiplied by the number of days per year, I get slightly different than that, but it was close enough that I assume that's where that calculation comes. It gives you a 27,000 roughly uncompensated annual patient days. And then I don't know if I quite understand the adjustment for the non DRG payment. But that's okay for this. We adjust it. And we get the adjusted uncompensated annual days. And then you have a you have a measurement of your direct cost per day of 22 22. And then you end up with $52 million in uncompensated care. And this quantifies the burden that UVM MC is seeing on this big, big challenge of, of it's not just post acute care. It's, you know, as we've heard from other hospitals, it's it's patients who don't actually even have significant medical need. So that skilled nursing facility and qualified for skilled nursing facilities, people are talking about paying for hotel rooms, apartments, other things. But this is the complex reality of what we're seeing is is the real big challenge here. And that costs about $52 million in 2022. That seemed fairly accurate. It does. And just to maybe explain a couple of the numbers there, Dr. Merman that may not have made sense. So the 15, the 15% adjustment for non DRG payment, what we're doing there is saying essentially some of those days that exceed the expected length of stay will we're likely still getting payment on meeting that care is compensated. So that's why we're adjusting the numbers down. And that expected length of stay is again, this analysis is not perfect. You know, we had to we had to put something together that attempts to get at this. But the expected length of stay is the closest thing that we have to what the DRG length of stay would be meaning once you extend beyond that 5.2, you're essentially not getting paid for that for that care. So hopefully that helps to tie together a couple of those a couple of those variables. Okay, I think I appreciate that I understand that. All right. And then so for the sake of the argument, I think you just standardize the average cost per day as the same over the three years, more for ease of calculation, there's probably some adjustment to that cost. But for the ease of this calculation and to sort of illustrate a point, I think that that was that was equal for those days. And then it appears that in 2023 was that was it was a harder year even then 2022 with $60 million of almost $60 million of uncapped care off of this model. But the budget for 2024 looks optimistic that you're hoping to save $10 million, essentially here in uncompensated care, or which I think is essentially due to a reduction in the actual length of stay. Is that where that's coming from? So exactly. Yeah. So Dr. Merman, we've done a huge, huge project at the Medical Center, a throughput project. And we've worked with case management, the physicians, we have patient placement rounds, both the Medical Center across the network to move people out to more appropriate locations. We've had some positive results over the last quarter of this year through great work by the providers and teams here. And we project that to continue into 2024. What's what's working? I would say it's better communication between providers, case management, the floor, setting a discharge date on the day they show up, and then daily patient placement rounds where the issues are being addressed in real time so it doesn't get to that Friday afternoon when you realize the person doesn't have the wheelchair at home or the one last thing they need to go. So I would really say it's better communication and real focus. We've put major focus into this this spring as we need it for access. We need those beds that are being taken up by people who don't need to be at the Academic Medical Center for someone else who does. Yep. And is this this, I believe is ECG, which I thought was a nice name being in the medical field of a consulting company. But is this the ECG work that you were referenced in the submission? It's both local and ECG work. Yes, we've done a lot of work as well. We use their help as well. Okay. And then and then so and just to sort of discuss this in a little bit more detail. So when patients are having a higher length of stay, it leads to other, you know, maybe not downstream but upstream issues to get patients into the hospital. And so I would assume that higher lengths of stay for inpatient admissions have an impact on Dr. Leffler, Yura and my specialty of emergency medicine, longer ED length of stay. Is that is that something you guys have experienced? Without question. So when I commented earlier about having five patients per day that we declined in December, those are people that were probably stuck in an ED across the state of Vermont. Now we're down to two. That really is the throughput work. That's having a bed available for those people from across Vermont to come and get the tertiary care they need. Okay. And so are there so are there other factors that you look at in this data other than the inability to transfer patients to these settings that are leading to increased lengths of stay compared to the comparison group? Dr. Remember, if I may, Dave Claus, the Network Chief Medical Officer. So yes, I mean, an initial analysis showed that a significant portion of our gap between actual length of stay and expected length of stay was related to poor capacity, inadequate capacity in our post acute settings. However, there was also a significant area for opportunity for improvement in our operations. Dr. Leffler has spoken about the value and the the positive impact that we're already seeing with initiation of patient progression rounds. In addition to that, there were major operational changes taken about on the inpatient floors at UVMMC and to some extent at other institutions in terms of going to a concept of unit based care, where essentially all the professionals were concentrated geographically in one unit to enhance their ability to function as a cohesive team. And so with those together, we are seeing slow but significant improvements in improvement in our in our actual average length of stay. Okay. So are the are the patients in the both both the actual and the the rest, did you want to say something? Very sorry to interrupt. Dr. Claus, you weren't on the witness list and I don't believe I swore you in initially.  If you're we're going to keep the discussion with you as a witness, I would like to have you under oath. Absolutely. I guess I did it without knowing I wasn't on the list before, but I'm happy to. Well, if you if you were sworn in before, then and you took the oath before that is fine with me if you just weren't on the list. Okay. Okay. So you're under oath. Thank you so much. Thank you. Thanks for us. Okay. So so I guess the question I have is in are all patients and in the actual and expected lengths to say, are they discharged to skilled nursing facilities or other post acute care settings? So I'm sorry. So this this encompasses patients regardless of their regardless of their destination after inpatient care. Okay. So this is this is all all admitted patients. So this is all admitted. Compared to peer groups. So okay. So they're patients in this in this data set that could have a, you know, have a two day length of stay and go home. That is correct. The Vizient data will actually decrease or will eliminate a certain percentage, the 1% of what they call outliers, the 1% in each DRG that has the highest length of stay. But aside from that, yes, all all comers and someone who is discharged the same day of admission is assigned a length of stay of one day. Okay. So so this data actually doesn't just represent long like as you as you said, you're working at you found other operational improvements and efficiencies through this process that are not related to skilled nursing facility discharges. So this data actually represents UVM's length of stay over the expected length of stay for all patients. And it could, a lot of that length of stay could be due to things other than the inability to discharge to an acute care setting, post acute care setting. So yeah, it's total. It's total on compensated care. Yeah. But we do know we've done a lot of study here that are observed or expected for routine cases that are going home is better than average. We do better on like like that's under one observed to expected. And our complex patients that have two or three comorbidities that need nursing on placement are way over observed to expected. So the people that are getting, you know, they're they're gallbladder out Dr. Merman, and they're supposed to go home in three days or oftentimes going home in two. We have good data on that. Okay. But okay. Dr. Merman, add to that because I've dug in by service line, etc. on where we have the actual average length of stay higher than expected. And the way the system calculates is if we've had a patient that's been here for 200 days, let's say, and they get discharged, it goes into that calculation for average length of stay. So I want to make sure that we understand that even though the number is higher, we've actually made significant improvement in being able to place some of our longer term patients. And that uncompensated care will go up when we discharge that patient because that is when the actual billing will drop through. Okay. I guess I was just trying to understand this chart. And I guess to me, it sounds not exactly what I'm looking for in that it's not defining who are the patients that are hard. Who are these I think you used the term in here? Hard to discharge patients or patients that need post acute care or other settings compared to a peer group patients, right? We're not taking a subset of patients that are hard to discharge and comparing them against that other subset of patients that are discharged. We're taking all patients and comparing them to all patients. And in that we have a pretty heterogeneous group of patients. So when I look at this $52 million of uncomped care, you know, a lot of things could be driving that other than just the inability to discharge a patient to subacute rehab. It is total patients. It is total uncompensated care. And I think as Dr. Leffler and Dr. Klaus pointed out, the largest piece of that is the inability to discharge patients. But if you're looking for another breakdown, I don't believe we were asked to provide that in the narrative, but we're happy to try to do that for you. Yeah. Indicate the estimated annual expenditures associated with providing care that cannot be reimbursed through the inability to transfer patients to post acute care or other appropriate care settings. So that would be helpful to get a little bit more clarity to answer that specific question. Because I think that what we're looking at is the one way one could look at this, and I'm not saying this is exactly right, but you could look at the cost of the increased length of stay throughout the EVM medical center and attribute all that cost to difficulty discharging patients. And I don't think you can say that with this data. I would love to read you a public comment that we received earlier this year that kind of relates to some of what you spoke about, Dr. Leffler, regarding the ability to take patients from other hospitals and some of what you were talking about, Dr. Klaus, about the internal operational efficiencies. So this came in in February. I experienced what seems to be a heart attack on Monday night, in which the copulate ER on Tuesday after determining that my symptoms of chest pressure needed to get checked out. In the ER copulate, I was accepted in the UVM system 24 to 48 hours to get in. Almost 48 hours later, I was transferred to UVM to a palatial room in Miller. It is now Saturday. I wasn't able to get my heart catheterization procedure yesterday due to other urgent cases that came in, and now I'm not sure if it will happen this weekend or not. I am so frustrated that I got delayed by going to Copley. One doc said I would have been taken care of had I gone straight to UVM, and now I'm so frustrated that I've had to fast for a second day while I wait for the elusive cath lab to determine if they will open today. This has cost me at least two extra days in the hospital. I'm a generally healthy person, so I didn't realize how screwed the system is.  My experience has been that no one knows when things will happen, will happen being stable now, and I'm at the bottom of the pile. This is very frustrating. I would suggest if you can't do cath procedures at a local hospital, then don't penalize patients coming in via the system and definitely open the cath lab on the weekend if they get backlogged. I don't, anyways, I don't want to get a nice experience at the hospital. I want to get diagnosed and go home. To me, this actually speaks to both of what you were speaking about there, the impact on other hospitals having to board patients that need to be transferred, but also that there's opportunity to decrease length of stay by improving access to procedures. So Dr. Merman, first off, February was right after December when we were delaying a lot of people. That's unfortunate. I hate that. The first thing I look at every single day on the census is how many people we couldn't accept last night. First thing I look at every day because it bothers me. It's part of our mission to accept those patients. Then to keep the cath lab open on weekends year and year, doctor, and you're aware that we have to have the cath lab ready on the weekends for emergent cases. So we have to call on a team. So every Saturday and Sunday, the cardiologist who's on call has to make the determination. If they took a stable patient to the cath lab and then the ER has someone who's highly acute or gets transferred here, that's a real problem. We don't have three teams on on Saturdays. So we try and manage that out, which unfortunately this person is right in everything they said. That means they unfortunately have to wait in our system. We are working on that, but right now we have one team on call for emergency cases. If there is a second one, we do urgently call a second one, but we don't typically have the cath lab running all day Saturday or Sunday with the routine cases to keep the availability open for the emergent ones.  It does it's very impactful for the system. And if there's any opportunity to look at surge planning number, you know, in these time periods where, you know, there's a high demand. I just want to make a comment. We could pay a full time second team to be on and do the routine cases, but that would drive up cost a lot. We have to pay special pay on weekends. We have to have an extra cardiologist. It's kind of what the whole thing we're talking about here today with cost and access. There's a balance to this point. We've said we're going to make people wait over the weekends. We could present a program to the Green Mountain Care Board that would have a second team on and do all those other cases, but that would drive up the expense. So I think that's the balance that all of us are working on today. That's a valid point. I think that I guess I wonder in that situation, and maybe this is a great discussion to have on another time as if there could be a surge plan to get through backlog and not live in backlog, which I think is your experience through the December, January, February timeframe. We've done that for many things. We are doing more cardiac cases during the week, but we haven't done it on weekends, but it's a fair point. But I would really appreciate if you could come up with a little bit closer to what you think is a realistic amount of money for what it's costing UVMMC to take care of patients who are awaiting, you know, who have long stays associated with difficulty of accessing post-acute care. I think a lot of these, actually, my questions have been addressed quite sure, Foster. A few questions have come up through conversations, not today, and we discussed it today about UVMMC's unique position of being the state's only academic medical center. So what are some examples, just from a standpoint of examples, are additional costs that are associated with being an academic medical center? So the first, you want me to start, Steve? Please. Yeah, go ahead. So the first is definitely the breadth of the services that we offer. So being a academic medical center and the tertiary and quaternary referral center for a region means that you're offering very expensive and highly specialized services. So that's certainly one of the impacts that we see from a cost perspective. The other is that we take all commerce. So the acuity of the patients that we see, because we are that referral center, means that we're taking care of much sicker patients than what you typically see in other hospital settings. So those are the two biggest, from my perspective, Steve and Judy, if you want to add, that would be great. Yeah, so the first thing I would say is that if you look at all the transfers we take over a year, we lose millions of dollars just on transfers. Other hospitals who find people that are complex and hard to take care of transfer the tune to us. It's actually our mission to take care of them. There are small subpopulations of patients who come that we actually earn a margin on, but many we lose money on. We lose significant money on dialysis. And in the state of Vermont, subspecialty care, because you need an even number of doctors, you can't have 1.6 pediatric oncologists, we round up and try and cover that. And we still have access challenges with that. So by providing the full breadth of tertiary care for patients in our region, but also our learners, there's a lot of cost, carrying cost to all those things and having all those services available in real time for people here. Yeah, I think that was actually, I wasn't expecting you to answer what it was a tertiary care center, but more of an academic medical center. So what I would say, it's a similar answer for, we provide many services here to make sure we can attract and train our learners for the future of health care. And so having divinity robots here, having things like that, that's what our learners need for the future. So they're ready to provide care when they are. Having capacity here to teach people the full spectrum of health care they're going to need to learn is expensive to do. There are services we do low numbers of patients on with high quality, but are expensive for the infrastructure for that.  I mean, so when we schedule medical students, my history of scheduling medical students with a primary care physician is you cut their load in a third to a half so that you can have the medical student learning residents, not that great an extent, they start slow so that you, when you start you have to put more effort in. Hopefully by the time they finish, they're actually enhancing your ability to deliver care. But overall, there's a cost associated with that, right? So those are, I think those are the very tangible costs. And I think Steve gave you the more sort of here's what we need to deliver in order to be a good academic medical center, but there's just a very specific tangible cost like you're not as productive working with a learner as you are working by yourself. I could set my table a lot faster than working with my three year old, right? And I actually think that relates all the way back to what we started this morning. It feels like a long time ago around the productivity of our academic physicians in clinic. I think this academic mission part of our work pertains to that. And that's why academic clinical targets are lower often. But it also would also just add one thing quickly are some of our cost or infrastructure costs, it, for example, some of the systems we need to do research and clinical trials are higher costs than nonacademic medical centers. So do and there's governmental and other grant revenue to cost to cover some of the costs of the academic trying to differentiate academic from tertiary functions, aren't there? Yes, any any type of grants that that are taking place, any type of research activity, almost all of that is certainly covered by an external source. But there is there is infrastructure costs that that again that are borne by the an academic medical center that wouldn't be completely covered. The other component we were talking about residency programs earlier today, you know, the residency program at the UVM Medical Center, obviously the number of residents outstrips the reimbursement that we get for for that that complement of residents. And I think many, you know, many academic medical centers have have done that one, because again, we're training the future generation of providers. So there's definitely there's definitely infrastructure components to an academic medical center that make them that make them unique. Are there are there academic functions that are not covered by grant revenue, governmental pay, its payers? And what is the cost of that? Yeah, I can't even you can't even separate that. Yeah, not really. I mean, it's such it's hard. I mean, if you just look at the salaries, just simply look at the salaries and look at the reimbursement, you won't hit the number. So just start with that, that what you get from Medicare, and you compare it to the salaries that we pay, you won't hit the number. And then on top of that, add on the sort of administrative load that you have to provide, the teaching opportunities that you have to provide. There's probably somebody that's done that David probably exists. I mean, the ACG and me probably has something and we could probably dig that up if that if that's important there. But but in overall, if you think about the benefit that we as an as a state in a region get from being an academic medical center, being able to be on the cutting edge on on much more forward thinking on where we want to go because of that, the opportunity to recruit folks and you know, bring them here, get them excited about the organization and the and the area and then keep them here. We've been incredibly successful with the recruiting part of that. I think all of that, I mean, you sort of have to balance that for the, you know, the organization and the state of the value of having an academic medical center on the academic part of it. So I think it's a complex math problem that I think there are probably people on both sides of that argument. I think that I guess the reason why I'm asking is it kind of speaks to your earlier comments, Dr. up and about the regulator's role in understanding the granularity of an operation that came up with CMI and that, you know, with really high skyrocketing insurance rates and the impact that's making on Vermonters and small businesses and individuals. Is at what point do we need to think about accountability for the costs of the academic training system compared to the benefits of the academic training system for the state of Vermont and for the people who are now paying those rising costs? And I think it's, it's not a, it's not a, there's not a clear answer. It's not a CMI. It's not a numerical value. But, but and maybe we need to think about as a state of where the more appropriate funding sources and maybe that's tax revenue versus high commercial insurance rates for a state where as, as, as Mr. Vincent mentioned, he doesn't have specific measures of Vermont's ability for moderate ability to pay for insurance, but our median income is 20, 20 points below the mean. I mean, it's, we have very low median incomes as a state. So for, and for a lot of people in Vermont who live in Bennington or Brattleboro or White River Junction or St. Jay, you know, that UVM is not really an available resource for them anyway. So it, it, it's a bigger societal question to me that it raises than a specific question in this budget. Dr. Herman, just a comment over the past couple of years, we've accepted many, many more transfers from Southern Vermont because partners around us are full all the time. So we're bringing many more people up here. And we know that about a third of the residents that we graduate stay in Vermont. And I would argue strongly, they do go to Brattleboro and Bennington and Manchester and Rutland and do help fill those sites. So in a real shortage of healthcare providers, having an academic medical center, which is training nurses, doctors, nurse practitioners to populate the healthcare system in Vermont, that's a huge benefit. I, and I totally agree with that. I just, I think the complexity is how do you quantify that?  Well, I quickly think this is building on Dr. Lefler's point. As we've looked the past few years, we've seen that more than four out of ten doctors across the state of Vermont, either trained at the Larner College of Medicine or completed residency at the UVM Medical Center, across primary care and special units. Yeah. I have one more line of questioning that I it's thinking about asking about, which is essentially you've, it's been discussed several times if the board does not approve your full budget request and the assessment of services going to be performed to figure out, you know, where reductions are going to need to be made. Last year, it says if we're forced to make reductions, we look at service lines that are low volume or do not cover their costs. So in 2023, did you do an assessment of which services would need to be cut? And what did you find? So go ahead. I think we're going to talk about, I think that's the conversation for the executive session, David, is like, rather than talk about that here. So we have, we have done a reasonable, not I wouldn't say thorough, but we've done a look at what we would need to do. So I think that's the part that we're saving for later. But I can tell you in general, that every year after we get our rates, we compare our rates to what we budgeted, we figure out what in short follows if there is one, and how we're going to adjust the budget, the budget's a plan for the following year. And in 23, after the rates came in lower, there were some other dollars that were coming that we were unsure of when the budget, we didn't even know about them when the budget was submitted, we were unsure of them at the day of the hearing. And then many of those dollars did come in, which allowed us to provide the services and expand access over 23 through a lot of hard work. And whatever rate comes in this year, however it comes in, we'll build onto the plan that we have to modify what we do to manage that. Thank you for that. So I think I'll try to ask questions in and around this area that if you feel need to go into executive session, please let me know. But when you are evaluating a service for a potential reduction, why is it that some services don't cover their costs? Pretty much all comes down to the reimbursement rate on that service. There's some services that we provide where the reimbursement, psychiatry for example, is a service that isn't reimbursed at a high enough rate to cover the costs. What we just talked about, the transfers or the uncompensated care, which I hear you will shrink the box in terms of what we're actually looking at. But that's another example of a lever where we don't have, we're not getting enough revenue to cover the costs of the care that we're providing for a large portion of our inpatient staff. So there's also volume. There's also volume, right? There's certain services that if you had enough volume of that service that you could then there's an accounting scale that's associated with it. So when you look at the example that you used about, if you had enough cat volume, then you could sustainably open up a second cat room running all day long because you know that there's going to be enough volume to be able to get compensated for that. But if you want to keep it open just for that urgent need, then you won't have it. And there are some places we have to do that. So if you run an OB service, you've got to be available 24 seven regardless of the volume and the cost, the fixed cost of that is really high. If you have enough volume, that's fine. You can do it if you don't, right? So there's both of those. There's the reimbursement piece. There's the volume piece as well. And with regards to reimbursement piece, I just want to pick up on the reimbursement piece for a minute. So when you're negotiating with commercial insurance, so at the end of the, you get the green mount care board gives the budget order you negotiate with the commercial insurance. Say like last year, is this like an across the board even increase to reimbursements? Or do you have abilities to negotiate specific service line increases up for some, maybe less up for others? So it's not across the board. And actually we can have Kelly Lang give you a little bit more detail on exactly how that's done. But even within the individual service lines, we have to, we're keeping an eye on where we need to stay within bounds. So it's not that you can increase a particular service line beyond what the typical market rate is. But we don't do it across the board. We do look at service by service to allocate that that rate increase. So Kelly, I don't want to add any more. Also, you know, we're just service by service and inpatient outpatient professional. So again, the different buckets of care based on how the payers reimburse payers having different methodologies. So is there ever a concerted effort to take the essential services of a safety net hospital and negotiate higher reimbursement rates for those comparative to other reimbursement increases? I'd like to discuss the contracting and sorry, Eric was going to beat me today. I think this is part of executive session conversation. Yeah. But at a high end, David, I mean, when you think about also that when you open up a particular service, it's not just your commercial payers that are using that service. So there's Medicare and Medicaid that are a majority of that. And the payment system and the vagaries that are associated with what gets reimbursed well and what aren't are largely out of our control. All right, does that make sense? So like, you can go for that all you want. But the reality is, is that lots of that is preset and unfortunate in America and the way that we've chosen to pay for some things and not chosen to pay for others. I think I'd like to talk more with you all in executive session about the details of this. I think for now, I'm going to pass off to whoever's next. Unfortunately, I don't think Professor Holmes has been able to join us today. So I think only Tom Walsh is left. Thank you so much. Yeah. So Dr. Merman, I'll, I'll call lunch break now just so Cassidy and everyone can have a break. Why don't we pinch it to 45 minutes instead of the full hour? And then we're obviously going to go over. There's going to be healthcare advocate questions and some other things. So everything will get pushed back a bit. And I appreciate everyone understanding that. It's a really important decisions and UVM should have the opportunity to address all the board member issues. So thanks for your patience. We'll probably go to maybe six o'clock tonight or something like that. So could be longer, could be less, but thank you for your patience. And we'll see you in 45 minutes. Thank you. All right. Well, well, that's what we'll do. Yes, it's fine. I can wait. I can be patient. Okay. Yeah. We'll do one more board member and then we'll have public comment after the HCA. Understood. All right. It looks like everyone is back. So Cassidy, we'll reconvene the hearing. And I think Tom Walsh, Professor Walsh may have some questions for UVM. Thank you, Chair. And welcome back, everyone. Hope you got to step outside. It's a beautiful day here in Vermont and thankful for it. I'm not a lawyer, so I don't really have a lot of actual questions. I do think that as we started off the hearing with a meeting, we all noted how we share a commitment to helping develop an affordable, accessible, high quality healthcare system. Having been a clinician for 20 years and now a professor of health policy and now a board member, I also think it's important that we think about evidence-based medicine and how, as a clinician, when new evidence emerges, we change. We want the, Vermont should understand that we would change our treatment as new evidence came in. As regulators, we should also change as new evidence comes in. And we should be keenly aware of the evidence that's available to us. And so most of what I have prepared to talk about has been a look through an evidence-based lens through the submissions we've received about budgets. And so I'd like to start off with utilization. You know, assessing utilization is difficult because we tend to think of all utilization as good, but it's not, right? We'd like increased utilization of effective care, preventative care, primary care, but increased utilization of care that's proven to be ineffective, or care that's high-cost, unproven quality. Those things we want to be more cautious about when we're trying to develop an affordable and accessible system. So when we're trying to get grip on a concept-life utilization that's difficult, it can be helpful to have a standard way of using it. And when we have a standard way, like with the Medicare cost report, everybody who fills it out, which is everybody who gets paid by Medicare, follows the same instructions to fill it out. There's some discretion involved with how we do it, but follow the same instruction. And then we can look at it the same way. UVM has asked that we use external benchmarks in the past, and now we've started using them. But when the numbers come in a way that you're not quite comfortable with, you want to be seen as different or unique or special, or develop your own methods for calculating something like utilization. And we see statements in the August 17 letter that said, using your own methods for calculating utilization. It's actually 50% of what is seen in the Medicare cost report. That's not evidence based. I looked for evidence about your method for calculating. I thought it was kind of an interesting idea. I could try with the IRS to say how I calculate my income is actually 50% of what they're saying it is. But it doesn't always work that way. So we're using a standard way of doing it. And I wanted evidence about how you've used what you've done to calculate it. And you said in the 817 letter to look in your narrative. And when I look in the narrative, a lot of what you've written about utilization goes back to the Dartmouth Atlas, which interests me greatly because I've said before that the Atlas has limitation. I teach people how to use the Atlas as part of my other job. And in your narrative, and when people who are advocating for you call in to the board, it's often said that the Atlas is the gold standard of measuring utilization. That's inaccurate. That's old. In 2015, a new bit of evidence came out that said what the Atlas shows is true for Medicare, but it's not true for patients with commercial insurance. In fact, it can be quite different. You can be a low-cost Medicare facility, but a high-cost commercial facility. And that's what the evidence shows UVM to be. That paper that came out in 2015 was kind of obscure, but it ended up in the New York Times. The title of the article was Doubt Cast on Medicare as a Model for Healthcare Reform. Experts were wrong about the best place for better and cheaper care. That study has been followed up over and over and over again, including in 2022. The study and all those studies were conducted by the second in our speaker series last spring, which Dr. Merman talked about. I encourage you, just like Dr. Merman did, please, please see those videos. Four speakers. The compelling regulator from Montana, Maryland, was the last. That was the least evidence-based presentation. Please watch the first three. So your justification for utilization numbers are kind of home-baked or based on outdated evidence. And I bring that up not to be mean or not to be confrontational, but because if we're going to have a conversation about evidence-based regulation and trying to move toward building a healthcare system together, we have to be able to talk about what's current, and what's not, what's selective, and what's holistic. So teaching at Dartmouth, I want to make one ask during this. I wish you'd stop making the erroneous claim that the Atlas is the gold standard. It isn't any longer. I say that as someone who teaches there. I'd like to talk about the RAND data next. The researcher who conducted all of the RAND studies on price transparency is Christopher Whaley. He was the third of the fourth speakers we had in the spring. I spoke with him yesterday to make sure that what I'm about to talk about is accurate. He's not a friend, but he's a colleague, and he's nice. He'd be available to any of you if you wanted to learn more about the RAND information. In the 817 letter to the board, you used inpatient data to talk about standardized and relative pricing, teaching hospital reimbursement. You went into greater detail about that on pages 15 and 16 of your narrative. The focus on inpatient standardized pricing being similar at Dartmouth and UVM is true, but it's selective. It's cherry-picked data because the difference really lies in outpatient care where the outpatient prices at UVM are 52% greater than the prices at Dartmouth. So when we convert those standardized prices to a relative comparison, that's what makes the relative comparison where UVM's prices are so much higher than Medicare. So I want to work through that for a second because the RAND data can be really helpful if we walk through it slowly. It's possible to see how UVM's high outpatient prices create a total facility fee that's very high compared to Medicare and way above what state health policy people estimate would be necessary for a hospital to break even, to run, not making a big profit, but run. UVM's total facility relative price to Medicare is 319.4% of Medicare reimbursement. Dartmouth's is 176.7%. The break even point, what price would UVM need to charge commercial payers in order to make enough money to keep everything running, is estimated to be 173% of Medicare. Dartmouth is 156%. So Dartmouth has a relative, its relative price is 21 points over the break even, while UVM's is 146 points over. And that's driven not by inpatient standardized prices, but by the outpatient standardized prices that are 52% greater and do not show up in any of your submissions. So this is a pattern of saying what you want, standards, benchmarks, transparency, but then when the results are not flattering, telling us we should see things your way, based on only the information you choose to share with us. And that information is often outdated and incomplete. We can't build the system that we all agreed is our mission when we're communicating that way. I'd like to next turn to your concerns about the cost report and start with a ratio of admin to clinical. You've explained that the shared services at the medical center that are part of the network inflate that ratio in the cost report. And you rightly show that we could remove that to better understand what's actually happening at the medical center. And when we do that, your ratio drops from 31 to 24%, which is within the benchmark, but on the high end. The point of having shared services is to decrease the expenses at the mothership and the affiliates. But when we look at the ratio of admin to clinical at your affiliates, Porter's middle, it's not low, it's middle, and CVMC is still very high. So the shared programs that you're describing do not seem to be, I can't find evidence of them producing any savings. They're an extra layer on top of the existing infrastructure. It's an added layer of administrative administrators and executives on top of the existing layers that are already at the mothership and the affiliates. That's at a time when we need more care providers. I want to talk for a moment about acuity and costs. Dr. Merman asked some questions about this. I think it's a tricky thing. You pointed out to us repeatedly that Vermont is the most rural state in the country. And the combination of a critical access hospital and an academic medical facility is rare across the country. The examples that you've provided of the rareness of a critical access hospital and an academic medical center are all urban. You mentioned Boston, you mentioned Chicago, where in one block there can be a critical access hospital and an academic medical center. So while it's true that the combination of critical access and academic medical center is rare across the country, it's not rare in rural settings. Tom, do you mean a safety net hospital, not a critical access hospital? I could be mistaken with that. Correct me, Dave. It's the combination of that we see here. I thought it was critical access and academic medical center. Am I wrong in that, Dr. Merman? I believe UVM and Sarah could speak better to this as a sole provider and a self-referred safety net hospital, but does not have critical access reimbursements. So my point, thanks for bringing it up. I'm a little bit nervous and may have misspoke. But my point is that the combination being the facility where everybody goes for their regular care or their routine hospitalizations and an academic medical center, while that may be uncommon when we look across the full country, if we look at just rural settings, it's not that uncommon. So the uniqueness that was being claimed earlier is not as unique in rural settings. The acuity concern conversation today, I got quite concerned about not just what I was reading in submissions, because providers always think that they're undercoding. Well, the evidence suggests that as soon as we start using electronic means to monitor our coding, we start up coding. And that evidence is found by looking at patients before looking at the the length of stay and the death rates before the new electronic medical record begins and the length of stay and death rates after it begins. Patients appear sicker because of higher intensity coding. But in the record and in the billing, but they don't die any sooner, they don't stay in the hospital any longer. So the up coding, the drive to get to 2.3 so that the cost per adjusted discharge looks better doesn't mean you're accurately capturing what's happening to patients. It's driving revenue. And when we look at things like adjusted discharge across a wide number of facilities, we realize that coding has its ups and downs. Everybody's trying to increase their coding lately. But the law of large numbers is that if everybody's doing that and we look at the average of a group as everybody, everybody moves toward more intensity, any 1 facilities place in that distribution won't really change the whole distribution shifts. So I think that that that comes up again and again throughout this report where you're describing being upset about where you are in the distribution and talking about your unique features. Well, each of those facilities there has uniqueness. And that's why we're using averages to smooth that out and look at how you do compared to other similar places. There was a comment made during the this morning's material where someone suggested that the board maybe should have been paying more attention to acuity and noticed if the acuity was less than we anticipated. I am trying to bring us as a board to make us more aware of the evidence so we could notice more things like that. Right. By comparing what's known about evidence to how hospitals in Vermont are performing. But that question really begged the question beg to follow up is what else do you all think the board should be paying attention to where maybe you're not performing as well? Like what else could we be missing? So I don't expect anybody to answer that, but it's an interesting thing to think of. So I'll conclude. We're beginning to use standardized benchmarks and our deliberations as you've wanted as we need to do evidence-based regulation. I believe that we all want evidence based care evidence based regulation and to understand how to best use the data to improve access affordability and quality and the financial positions of the hospitals in our state. But when you're submitting selective information that's out of date or incomplete to fight data that shows where you could improve, that makes it difficult to further this mission. I wanted to say these things in public, have them on the record. I don't really like doing it this way, but it's important that this be said publicly so that we can deliberate together to make the system that we want. I'm looking at my notes. One more thing, one more topic that Dr. Mermitt had that I hadn't written down in before he spoke. I want to comment really quickly on what's known as price discrimination and used to be thought of as the cost shift. We had four guest speakers last spring. The first conducted a study. Dr. Stenslin, Jeffrey Stenslin conducted a study in 2010. A small group of hospitals showed hospitals don't have to cost shift. Hospitals that have the market power to tolerate commanding higher commercial prices do that. Hospitals without enough market power actually cut their prices to Medicare or lower to stay competitive when they're in competitive markets. That study turned our ideas about cost shift on its head. It's very controversial, but it's been repeated now with more hospitals in different settings and by different researchers. Until in 2017, the study was redone with every hospital, including all of Vermont's. Hospitals that have the market power to raise prices far above what Medicare pays do so. They're not compelled to. They choose to because they have market power. Hospitals without the market power do not raise their prices similarly. Hospitals that are able to command higher prices, that money shows up in growing infrastructure, expanding administrative roles, and higher than average executive salaries. We've seen that evidence across the country. We use the Medicare cost report to look to see if that was true in Vermont. And it is. So I encourage you to watch those videos. The first three are the most important and understand price discrimination and the choices that are available to you. And I'll conclude there. Unless I left anything off, Dr. Merman, please. Let me know. But I'll turn it back to Chair Foster. One quick follow-up I had. Maybe Mr. Vincent, you're the right person, but I'm not sure. The CMI work that's underway. Will that have any impact on MA plans? It tends to. It tends to be the business model for MA plans to raise the acuity of to use coding to raise the apparent acuity of patients to get higher reimbursements for those patients who, when compared to patients who are in regular Medicare, they have similar lengths of stay, similar death rates.  There's a terrific study looking at patients who moved across the country, moved to different places in the country that really goes into great detail about that. So, yes, it does affect MA plans substantially. So, yeah, I'm aware of some of the litigation nationwide against MA plans for this, going through the record to find additional diagnoses that DOJ has been pursuing. And I just wasn't totally understanding whether or not this project, not that it's like the fairest, but I'm just asking, even if it's like appropriate, would this have an impact on MA plans? So, where you're seeing those cases, so where you're seeing those cases is really on the outpatient services, chair Foster. So, there's another type of acuity coding called HCC coding. So, higher optical category coding, that's where you've seen the MA plans really try to push the acuity of the patients. To be clear, again, what we're basing our CMI work on is that we know that we've looked at our documentation and coding, and we've looked at what's happened to the patients, and we're not accurately doing it. So, we feel very... Let me cut you off, because I think I asked it poorly. I'm going to assume that the CMI work you're doing is going to 100% get everything right, okay? That you're going to just get paid what you should get paid. That's my presumption, and I'm sure that's what we all want. If it does that, and it does it correctly, and bumps it to 2.3 appropriately, what impact will it have on MA plans, if any? So, it'll impact any Medicare patients. So, if we do have a Medicare MA plan that will impact the revenue there as well. So, I'm wondering, Chair Foster, do you mind if we comment on just a few of the points that were raised by Tom Walsh? If you'd like to, I don't have any objection to that. If you want to save it and send it to us in a letter, that's fine for time. If you want to do it now, totally fine. Your pick. I think with all of our team here, I think it would be good just to maybe hit on a couple of the points. So, first of all, to start, we absolutely appreciate the metric driven process that we have this year that's been a major improvement in the process. We're not upset with the results. Actually, had the tool been presented to us earlier in the year where we could have actually reviewed the data that's in the tool. We could have had a great dialogue about ran studies, vision data, rating agency reports. There's no perfect benchmark. And so, what we're striving for here is truly a dialogue. So, the letters that we're sending to you, the way that we're looking at the data is not because we're upset. It's because we haven't had really any type of chance to really talk about the metrics that are used in this year's budget process. It was certainly in the guidance where we had a list of the things that could potentially be used for the budget, but we certainly didn't have access to be able to see the data and be able to dig in to see exactly how this looks. So, we're certainly open to a dialogue, and that's why I said in my opening remarks that I really appreciate the start that we have here, but we definitely need some more work just to get on the same page in terms of what the appropriate benchmarks are. In terms of the comment of the utilization, that is the holy grail, trying to decipher between what's bad utilization and what's good utilization. Are we doing things unnecessarily for patients that are reordering lab tests and x-rays that we don't need to be ordering versus good quality evidence-based care that's driven by protocols? We absolutely have that same goal, and I think for us as an organization, we've been on that path with many, many programs throughout the years, whether it's choosing wisely. The fact that we're in value-based programs that looks to impact the cost of care and the utilization of services, I think we're definitely all on board with that. In terms of the benchmarks that help to drive at that, that's why we've used the Dark Myth Atlas, realizing that the data is dated yet and it does get updated, is that does remove some of the noise out of the system and looks at just there's no payment variation, there's no other external facts that cloud the amount of utilization per Medicare beneficiary. That is why we keep referring back to that. We're trying to get at that question, what is bad utilization and what is good utilization? That is how we're using that data, is to say that we're only doing what's absolutely necessary for the patients that we're caring for. In terms of the 50% utilization comment, the point that we were trying to make there is, again, we don't have perfect data, but when we're looking at our utilization over a period of time, there is some of our volume that comes just purely from taking care of more patients. It's not doing more with our existing patient base, but it's just a growth in the population and we're taking care of more people. The administrative costs, I just want to touch on that briefly. The point that we were trying to make there in the letter that we sent is administrative shared services, so HR, all of us, UVM health network leaders here on the screen, IT, revenue cycle, that's administrative shared services and we do have benchmarks that look at that. In the tool, again, a discussion that we certainly could have had because there's other ways to look at this, the tool is looking at general and administrative salaries as a comparison to clinical salaries, so that general and administrative category includes essentially everybody that isn't clinical, so it includes the housekeepers, it includes facilities, personnel, it includes everybody that you wouldn't consider a administrative shared service that is supporting the network, so that's the point we were trying to highlight in the letter that we sent. Finally, I think there is a lot of work we can do with the RAN data. We have some internal expertise that I think together with the board staff, we can get to a better place of understanding how we may be different, how we may not be different, but I guess I'll just close in saying that no benchmark data is perfect. We're not upset with the benchmarks that are being used. I think with more time, we can get to a better place and that was the whole point of the letter that we sent to you was just to highlight and clarify where a benchmark may not be perfect and we still have some more work to do. Thank you for those thoughts, Mr. Vincent. I agree, benchmarking tools really helped us and your letter helped us think about your perspective on those data points, and so that was valuable for us in evaluating it also. Thanks for putting the time in to do it. I'll turn to the healthcare advocate for any questions they may have. Thank you, Chair Foster. We'll do public comment after just for I know folks are waiting, but sorry to interrupt, Mikey. Yep. I have a few questions and Sam, vice from my team will have a few questions. So first off, thank you. Then a long day already and promises to be even longer. And also thank you. I should pause for minutes and express a thank you through you to all of the vast number of providers under you who are providing care. I think I know others feel the same. We have challenging questions at times, but that doesn't mean that we don't appreciate the work that is represented here. So first off, I have a question about your Part C partnership with MVP, and as I launch into it, I'm sure I trust you will alert me if I stray into questions that should be answered in a confidential setting. In answer to a question that was asked by the board about the UVM MVP partnership, you answered that UVM does not currently have an ownership interest in the MVP Part C plan. And so I guess I wanted to ask maybe maybe in follow up to that. So are you saying that if this plan does well and is profitable that that will have no impact on UVM's bottom line? That's correct. Right now we have a co-branded product in the market, but MVP is solely responsible for the performance of that plan. We don't have any connection to the financial performance of the UVM health network advantage plan. Okay. I was going to maybe I'll ask it anyway. I had a sort of a version of the case mix question for Part C versus quite a lot of questions already about case mix, but I guess I wondered whether you have an analysis of your case mix for even though you don't have an ownership interest for the Part C plan in comparison to other Medicare? Sorry. No, we don't have that comparison. Okay. While I'm talking about Medicare and Medicare costs, I do want to just pause for a second. This is a comment more than anything. Whenever I hear people talk about Vermont being a low cost Medicare state and referencing the Medicare benchmark data, I believe we're talking here about traditional Medicare. And I just think it's really important for us all to remember that at least up until recently, Vermont has had a low uptick in Part C. And I think there's been a lot of analysis that Part C plans tend to take lower acuity, lower cost people out of the marketplace, out of the rest of the traditional group. So states with a lower uptick of Part C often will look like they cost less. There's a lot of analysis on that and I could certainly point you to it. There was one, it actually done in state as part of the Act 99 report recently. So follow up on member Merman's question about the medical school. In addition to the costs that he explored in his questioning, I also see, I think it's in addition, if you could clarify, I also see in your audited financials what appears to be a transfer to the medical school annually of in the range of $20 to $30 million. Is that in addition to the dynamics that member Merman explored? No, the transfers that they're going to UVM are to pay for specific costs. So some of that cost is the cost of physician salaries that a portion of their salary is at UVM. But for that time, they're actually providing clinical care. So UVM is reimbursed for that piece of the salary. Some of that is benefits. With our physicians, they essentially have a choice where they get their benefits. The ones that are duly employed by UVM and the UVM medical group, they can choose to get their benefits through UVM, or they can choose to get their benefits through the UVM medical group. So that cost is part of that transfer. Plus, we do have some space that we occupy at UVM. So the transfers are all connected to an actual operating expense that we should be paying for as an academic medical center. Okay. I will leave that topic with it with, hey, by the way, no one's questioning the importance of the medical school here. I think the question really should be, what's the right way to fund it? And so I think that it would be an interesting question to evaluate whether other states have found other ways to fund it other than through rate payer dollars. That's the place where I find the need to push back as to whether the rate payers is the right way to fund that part of the medical school. In follow-up to Mr. Vincent's earlier comments about the bond rating, about your rating, I wanted to ask you a little bit about the obligated group. It was curious for me to understand that the entity that is rated here is not the whole UVM health network. It is less, maybe Porter and Alice Hyde and a couple of other small entities. Can you explain why that is? It's just based on history. And actually, on October 1st of this year, those groups will also, those two hospitals will also be in the obligated group. But to be clear, the rating agencies have always looked at us as a health network. The obligated group to them doesn't matter when they're looking at financial performance that are looking at car and they have been looking at our entire health network. Okay, that's interesting to me. I thought I was understanding that the rating was only on the entities in the obligated group. You're saying it's everyone. So I want to note that it's similar to my question about the medical school. I want to focus on the cost of the health systems across the lake. And similarly, I'm not questioning whether those hospitals should be supported and really meaning to ask, is it Vermont rate payer dollars that should be supporting them? And you know, I recognize from their audited financials that I've been talked about. I encourage you just like Dr. Murma did, please, please see those videos. Four speakers, the compelling regulator from Montana, Maryland, was the last. That was the least evidence based presentation. Please watch the first three. So your justification for utilization numbers are kind of home baked or based on outdated evidence. And I bring that up not to be mean or not to be confrontational, but because if we're going to have a conversation about evidence based regulation and trying to move toward building a healthcare system together, we have to be able to talk about what's current, and what's not, what's selective, and what's holistic. So teaching at Dartmouth, I want to make one ask during this. I wish you'd stop making the erroneous claim that the Atlas is the gold standard. It isn't any longer. I say that as someone who teaches there. I'd like to talk about the RAND data next, please. The researcher who conducted all of the RAND studies on price transparency is Christopher Whaley. He was the third of the fourth speakers we had in the spring. I spoke with him yesterday to make sure that what I'm about to talk about is accurate. He's not a friend, but he's a colleague, and he's nice. He'd be available to any of you if you wanted to learn more about the RAND information. In the 817 letter to the board, you used inpatient data to talk about standardized and relative pricing, teaching hospital reimbursement. You went into greater detail about that on pages 15 and 16 of your narrative. The focus on inpatient standardized pricing being similar at Dartmouth and UVM is true, but it's selective. It's cherry-picked data because the difference really lies in outpatient care, where the outpatient prices at UVM are 52% greater than the prices at Dartmouth. When we convert those standardized prices to a relative comparison, that's what makes the relative comparison where UVM's prices are so much higher than Medicare. I want to work through that for a second because the RAND data can be really helpful if we walk through it slowly. It's possible to see how UVM's high outpatient prices create a total facility fee that's very high compared to Medicare and way above what state health policy people estimate would be necessary for a hospital to break even, to run, not making a big profit, but run. UVM's total facility relative price to Medicare is 319.4% of Medicare reimbursement. Dartmouth is 176.7%. The break-even point, what price would UVM need to charge commercial payers in order to make enough money to keep everything running, is estimated to be 173% of Medicare. Dartmouth is 156%. Dartmouth has a relative, its relative price is 21 points over the break-even, while UVM's is 146 points over. That's driven not by inpatient standardized prices, but by the outpatient standardized prices that are 52% greater and do not show up in any of your submissions. So this is a pattern of saying what you want, standards, benchmarks, transparency, but then when the results are not flattering, telling us we should see things your way, based on only the information you choose to share with us. And that information is often outdated and incomplete. We can't build the system that we all agreed is our mission when we're communicating that way. I'd like to next turn to your concerns about the cost report and start with the ratio of admin to clinical. You've explained that the shared services at the medical center that are part of the network inflate that ratio in the cost report, and you rightly show that we could remove that to better understand what's actually happening at the medical center. And when we do that, your ratio drops from 31 to 24%, which is within the benchmark, but on the high end. The point of having shared services is to decrease the expenses at the mothership and the affiliates. But when we look at the ratio of admin to clinical at your affiliates, Porter's middle, it's not low, it's middle, and CVMC is still very high. So the shared programs that you're describing do not seem to be, I can't find evidence of them producing any savings. They're extra layer on top of the existing infrastructure. It's an added layer of administrative administrators and executives on top of the existing layers that are already at the mothership and the affiliates. That's at a time when we need more care providers. I want to talk for a moment about acuity and costs. Dr. Merman asked some questions about this, but I think it's a tricky thing. You pointed out to us repeatedly that Grumman is the most rural state in the country, and the combination of a critical access hospital and an academic medical facility is rare across the country. The examples that you've provided of the rareness of a critical access hospital and an academic medical center are all urban. You mentioned Boston, you mentioned Chicago, where in one block there can be a critical access hospital and an academic medical center. So while it's true that the combination of critical access and academic medical center is rare across the country, it's not rare in rural settings. Tom, do you mean a safety net hospital, not a critical access hospital? I could be mistaken with that. Correct me, Dave. It's the combination of that we see here. I thought it was critical access and academic medical center. Am I wrong in that, Dr. Merman? I believe UVM and Sarah could speak better to this as a sole provider and a self-afford safety net hospital, but does not have critical access reimbursements. So my point, thanks for bringing it up. I'm a little bit nervous and may have misspoke, but my point is that the combination being the facility where everybody goes for their regular care or their routine hospitalizations and an academic medical center, while that may be uncommon when we look across the full country, if we look at just rural settings, it's not that uncommon. So the uniqueness that was being claimed earlier is not as unique in rural settings. The acuity concern conversation today, I got quite concerned about not just what I was reading in submissions, because providers always think that they're undercoding. Well, the evidence suggests that as soon as we start using electronic means to monitor our coding, we start up coding. And that evidence is found by looking at patients before looking at the length of stay and the death rates before the new electronic medical record begins and the length of stay and death rates after it begins. Patients appear sicker because of higher intensity coding, but in the record and in the billing, but they don't die any sooner, they don't stay in the hospital any longer. So the up coding, the drive to get to 2.3 so that the cost per adjusted discharge looks better doesn't mean you're accurately capturing what's happening to patients. It's driving revenue. And when we look at things like adjusted discharge across a wide number of facilities, we realize that coding has its ups and downs. Everybody's trying to increase their coding lately. But the law of large numbers is that if everybody's doing that, and we look at the average of a group, as everybody, everybody moves toward more intensity, any one facilities place in that distribution won't really change. The whole distribution shifts. So I think that that that comes up again and again throughout this report where you're describing being upset about where you are in the distribution and talking about your unique features. Well, each of those facilities there has uniqueness. And that's why we're using averages to smooth that out and look at how you do compared to other similar places. There was a comment made during the this morning's material where someone suggested that the board maybe should have been paying more attention to acuity and noticed if the acuity was less than we anticipated. I am trying to bring us as a board to make us more aware of the evidence. So we could notice more things like that right by comparing what's known about evidence to how hospitals in Vermont are performing. But that question really begged that question beg to follow up is what else do you all think the board should be paying attention to where maybe you're not performing as well, like what else could we be missing? So I don't expect anybody to answer that, but it's an interesting thing to think of. So I'll conclude. We're beginning to use standardized benchmarks and our deliberations as you've wanted as we need to do evidence-based regulation. I believe that we all want evidence-based care, evidence-based regulation, and to understand how to best use the data to improve access, affordability, and quality and the financial positions of the hospitals in our state. But when you're submitting selective information that's out of date or incomplete to fight data that shows where you could improve, that makes it difficult to further this mission. I wanted to say these things in public, have them on the record. I don't really like doing it this way, but it's important that this be said publicly so that we can deliberate together to make the system that we want. I'm looking at my notes. One more thing, one more topic that Dr. Mermin mentioned that I hadn't written down before he spoke. I want to comment really quickly on what's known as price discrimination and used to be thought of as the cost shift. We had four guest speakers last spring. The first conducted a study, Dr. Stenslin, Jeffrey Stenslin conducted a study in 2010. A small group of hospitals showed hospitals don't have to cost shift. Hospitals that have the market power to tolerate commanding higher commercial prices do that. Hospitals without enough market power actually cut their prices to Medicare or lower to stay competitive when they're in competitive markets. That study turned our ideas about cost shift on its head. It was very controversial, but it's been repeated now with more hospitals in different settings and by different researchers until in 2017 the study was redone with every hospital. Including all of Vermont's hospitals that have the market power to raise prices far above what Medicare pays do so. They're not compelled to. They choose to because they have market power. Hospitals without the market power do not raise their prices similarly. Hospitals that are able to command higher prices, that money shows up in growing infrastructure, expanding administrative roles, and higher than average executive salaries. We've seen that evidence across the country. We used the Medicare cost report to look to see if that was true in Vermont. And it is. So I encourage you to watch those videos. The first three are the most important and understand price discrimination and the choices that are available to you. And I'll conclude there. Unless I left anything off, Dr. Murman, please. Let me know. But I'll turn it back to Chair Foster. One quick follow-up I had. And maybe Mr. Vincent, you're the right person, but I'm not sure. The CMI work that's underway. Will that have any impact on MA plans? It tends to. It tends to be the business model for MA plans to raise the acuity of to use coding to raise the apparent acuity of patients to get higher reimbursements for those patients who when compared to patients who are in regular Medicare, they have similar lengths of stay, similar death rates.  There's a terrific study looking at patients who moved across the country, moved to different places in the country that really goes into great detail about that. So yes, it does affect MA plans substantially. So, yeah, I'm aware of some of the litigation nationwide against MA plans for this, going through the record to find additional diagnoses that DOJ has been pursuing. And I just wasn't totally understanding whether or not this project, not that it's like the fairest, but I'm just asking, even if it's like appropriate, would this have an impact on MA plans? So where you're seeing those cases, so where you're seeing those cases is really on the outpatient services chair foster. So there's another type of acuity coding called HCC coding, so hierarchical category coding. That's where you've seen the MA plans really try to push the acuity of the patients. To be clear, again, what we're basing our CMI work on is that we know that we've looked at our documentation and coding, and we've looked at what's happened to the patients, and we're not accurately doing it. So we feel very... Let me cut you off, because I think I asked it poorly. I'm going to assume that the CMI work you're doing is going to 100% get everything right, that you're going to just get paid what you should get paid. That's my presumption, and I'm sure that's what we all want. If it does that and it does it correctly and bumps it to 2.3 appropriately, what impact will it have on MA plans, if any? So it'll impact any Medicare or patient. So if we do have a Medicare MA plan that will impact the revenue there as well. So I'm wondering, chair foster, do you mind if we comment on just a few of the points that were raised by Tom Walsh? If you'd like to, I don't have any objection to that. If you want to save it and send it to us in a letter, that's fine for time. If you want to do it now, totally fine. Your pick. I think with all of our team here, I think it would be good just to maybe hit on a couple of the points. So first of all, to start, we absolutely appreciate the metric driven process that we have this year that's been a major improvement in the process. We're not upset with the results actually had the had the tool been presented to us earlier in the year where we could have actually reviewed the data that's in the tool. We could have had a great dialogue about ran studies, vision data, rating agency reports. There's no perfect benchmark. And so what we're striving for here is truly a dialogue. So the letters that we're sending to you, the way that we're looking at the data is not because we're upset. It's because we haven't had really any type of chance to really talk about the metrics that are used in this year's budget process. It was certainly in the guidance where we had a list of the things that could potentially be used for the budget, but we certainly didn't have access to be able to see the data and be able to dig in to see exactly how this looks. So we're certainly open to a dialogue and that's why I said in my opening remarks that I really appreciate the start that we have here, but we definitely need some more work just to get on the same page in terms of what the appropriate benchmarks are. In terms of the comment of the utilization, that is the holy grail, trying to decipher between what's bad utilization and what's good utilization. Are we doing things unnecessarily for patients that are reordering lab tests and x-rays that we don't need to be ordering versus good quality evidence-based care that's driven by protocols? That's the, that we absolutely have that same goal. And I think for us as an organization, we've been on that path with many, many programs throughout the years, whether it's choosing wisely, the fact that we're in value-based programs that looks to impact the cost of care and the utilization of services. I think we're definitely all on board with that. In terms of the benchmarks that help to drive at that, that's why we've used the Dartmouth Atlas, realizing that the data is dated yet and it does get updated, is that does remove some of the noise out of the system and looks at just, there's no payment variation, there's no other external facts that cloud the amount of utilization per Medicare beneficiary. And so that is why we keep referring back to that. We're trying to get at that question, what is bad utilization and what is good utilization. That is how we're using that data is to say that we're only doing what's absolutely necessary for the patients that we're caring for. In terms of the 50% utilization comment, the point that we were trying to make there is, again, we don't have perfect data, but when we're looking at our utilization over a period of time, there is some of our volume that comes just purely from taking care of more patients. It's not doing more with our existing patient base, but it's just a growth in the population and we're taking care of more people. The administrative costs, I just want to touch on that briefly. The point that we're trying to make there in the letter that we sent is administrative shared services, so HR, all of us, UVM health network leaders here on the screen, IT, revenue cycle, that's administrative shared services and we do have benchmarks that look at that. In the tool, again, a discussion that we certainly could have had because there's other ways to look at this, the tool is looking at general and administrative salaries as a comparison to clinical salaries, so that general and administrative category includes essentially everybody that isn't clinical. It includes the housekeepers, it includes facilities, personnel, it includes everybody that you wouldn't consider an administrative shared service that is supporting the network. That's the po