t but that's all right and Dr. Hunter any comments you have? Yeah I think that's a great comment and similar to what Dr. Sanders referenced as we continue to navigate through health equity there's going to be a lot of different things that we have to unravel because as you reference racism has been a part of the healthcare system and delivery system for quite some time so we definitely are committed as we think about health equity to really start to tackle some of those areas and what partnership with my team and the presence as well that is something that we are very committed to doing Yeah thank you and again thank you for your work this is just a little bit of a different angle because it's a clinical question and it sounds like there's quite a few like it so thank you thank you for engaging One thing I'll add is that the medical center for our safe reports we've added DEI question to every single safe report that comes in right now so was DEI was the race an issue in this event and we're tracking those now and capturing those and we have actually made some changes to some of our reference ranges because the exact issue raised I know that renal function has been corrected I wasn't aware of the spirometer when I saw a lot of people in the ED in my lifetime so it's a good question we'll have to track that down Great you know similar closely related our people screen for sickle cell traits when patients come through your EDD and again you know I'm just adding it to the list these are the kinds of things that as we research it that makes sense to have have current for us maybe not okay so and then I think lastly I'll wait into the public payer potential for increases in public payer reimbursment topic and and I want to recognize that's been talked about quite a bit today and I appreciate the discussion Al about a dollar for dollar recognition of increase in public payer reimbursement on the commercial rates but I also want to recognize the you know your need to make the statement about the you know that you're willing to make this commitment if your entire budget is is funded and I don't know what the green mountain care board is going to decide for you I don't know whether you'll get trimmed by a couple of percent but I want to I just want I guess I just want to call out if we're going to do this it's not going to be easy the state share of money doesn't come from you know out of thin air we're going to have to raise it and and and I just make it as a as a statement I'm not I'm not expecting that your budget ask will go down by whatever we can increase through increased federal participation in Medicaid I fully understand that areas of your budget will continue to grow faster but nonetheless I think if we are able to assure that there's a dollar for dollar transfer from increased monies through Medicaid I'll say in this example to commercial it will make the conversation the public policy conversation significantly easier in my opinion yeah thank you Mike and we are making that commitment so okay thank you thank you for a really fun day good to see you Mr. Fisher good to see you Mr. Gobey Mr. Fisher I do have to question your definition of fun but I will I will move on from there the actually the next part of our agenda is actually to open it up for public comment and so is there anybody from the public that wishes to comment on this budget if you do have a comment please just use the the team's raise your hand function and I will see you and acknowledge you yes Mike Del Treco can you see me and can you hear me I can perfect so Chair Holmes I've taken notes of areas where you want Vaz to engage and we're more than willing to to do that work with the hospital so first comment and my comments not specific to the health network's budget but but just just a general comment on the week that we just went through so I'll just start by saying my name is Mike Del Treco I represent the Vermont Association of hospitals and health systems and all our members so thanks Chair Holmes board members Green Mountain Care Board staff and members of the public I know this process is complicated and taxing and thanks for your commitment to this important work I think it's important to pause and acknowledge what we've heard midway through this hearing process this week we've heard from critical access hospitals PPS hospitals and today the academic medical center each leadership team has outlined the deep challenges they are managing you've heard a great amount of detail about workforce challenges wage pressures shortages and travelers multiple years of steep health care inflation supply chain issues a trend of declining margins capacity issues related to sicker patients and patient flow hurdles because of broken mental health and long-term care delivery systems I said this before but I want to be very clear there's nothing normal about what our hospitals are managing today what what is particularly inspiring though is what we've heard from these hospitals about how they're managing through these difficult times for every challenge whether it's in their control or not our Vermont hospitals have created plans develop collaborations and have put policies or strategies into place to be able to continue to care for their patient support their staff and strengthen their communities our hospitals are creative they lean in when there's a crisis and they're not sitting idly by waiting for others to act they are leading and they are committed to progress but their teams are tired and stressed and in some cases really burned out and they need your help right now our delivery system is challenged and in very precarious situation we are at a major inflection point you heard about it today you heard about it all week and there are great consequences of not approving these budgets no matter what type of hospital critical access PPS or academic medical center in Vermont they are all community hospitals that bring care and hope to patients and their families as well as vitality to their communities we need strong critical access and PPS hospitals in every corner of Vermont and of equal importance we need a strong academic medical center to teach future doctors healthcare leaders care and treat the most complicated patients and to be a resource for all hospitals and every Vermonner any suggestion otherwise would be dangerous so again my ask is simple and with complete respect please approve these budgets as submitted I want to thank you for your dedication to this process and I look forward to hearing from the remaining hospitals next week and I will continue to take notes on where you want of us to engage and happy to do so and thank you for allowing me to speak today yeah thank you I appreciate it and you're willing us to follow up on some of those initiatives I think they're really important is there any other public comment again you can use the raise your hand function if you're on the phone just let me know and you can start speaking okay I'm not hearing anybody I'm not seeing anybody else so thank you to everybody I think there's really we do have sorry hi Robert Hoffman just briefly wanted to make a couple points in 2019 I wrote to this board and alerted you all that the failure of the all payer model to unlock greater value based care would ultimately come collide with bondholders at hospitals and here we are an existential request is being made against the best backdrop of a possible markdown to bonds and at that same time in 2019 I alerted you all to the widely understood economic law of Stein's law that what must end will end as Alan Rick Vincent shared the systemic issues facing these hospitals began long before COVID and current inflationary pressures patient access has been in decline since the APM commenced in 2017 it's data that for whatever reason your board doesn't share often or publicly but it's data that's well collated for those who are interested in looking at it in 2019 or 2018 nurses at the medical center decried both culture and wages executive to FTE wage ratio amongst pure academic medical centers in the region has been packed back of the pack for years lumber copper auto all inflation indicators as we speak many of them are in decline have corrected by more than 50% inflation is transitory UVM HN culture and management failures are not transitory and yet this C-suite is staffed and paid like they are batting a thousand what value did Ms. Wallach's $500,000 salary bring to today's discussions that Mr. Broomstead could not have handled what value did Algo Bay's $500,000 salary bring to the discussion today that Dr. Broomstead could not have fielded why does a $2 million a year CEO need $5 million worth of a C-suite to run a mere $1.3 billion organization I've worked at organizations four times that size with much smaller C-suites we are here because of long-standing mismanagement not transitory secular trends member Walsh highlighted this network's exercise and confirmation bias to pick and choose evidence to support its presentation other data points not shared are that they're 15% higher FTE than average 47% more beds than average 36% fewer discharges per employee than average personnel expenses 42% higher as percentage of operating revenue than average whether you fulfill this request or not Stein's law will prevail Walsh is right this rate increase will break the price elasticity demand in Vermont for consumers the whack-a-mole game that this network engages in may achieve their aim today to knock the head down in one area and the head will pop up somewhere else concurrently groups like Dartmouth-Hitchcock Blue Cross Blue Shield Vermont Clover Health and even the startup that I performed advisory work for revive healthcare where we deliver comprehensive primary care pharma and labs for $25 per member per month if our startup can do that at 25 what will Amazon's recent acquisition do in the same space whatever happens today is transitory irrespective of what decision you make UVMHN is an overly aspirational aged rural academic medical center trying to exceed the region's need whether UVMHN next year or in five years whether by market forces or Act 167 will return in time to its humble $500 million rural academic medical center in a state of 600,000 people who are struggling to make ends meet thank you okay thank you for your comments Mr. Hoffman is there anybody else who has a public comment they would like to make all right well this has been a long day I would say it's been an important day a productive day we've heard a lot of important information some exciting initiatives potentially but also a lot of work to do and I just want to thank everybody for coming for being here with us today and sharing your insights it was actually really lovely to meet some of your new team members at the health network and you know Dr. Brumsted again my best wishes to you as you move on to the best you know the next chapter of your life I hope you have a wonderful retirement I'm a bit envious um with that I would say the UVM health network you are off the proverbial hook for today there is some follow-up that Sarah will connect with you on I think there were some questions in there and hopefully the team has pulled some of those together for some questions that we needed a little follow-up on board members I would say not so much off the proverbial hook we'll be back online Monday morning at 8 30 we're going to be hearing from Rutland and Mount Ascotney so with that is there a motion to adjourn I move to adjourn okay I hear Tom motioning and I hear Robin seconding I'll take it that way all those in favor hi hi and you posed I would hope not we are adjourned thank you very much to everybody at the UVM health network for coming in today and spending the day with us online maybe next year in person hopefully next year in person thank you team Green Mountain Care Board