I see that all members of the board are here so I'm going to call the meeting to order and we'll start with comments from the executive director. Good morning. Thank you Mr. Chair. I have a couple of public comment announcements and then an update on a request that you made of me last week. First we're currently accepting public comments on the University of Vermont Medical Centers mid-year budget adjustment request and that information can be found on our website under our public comments as well as the public comments that we've already have received or posted there. We also encourage, as I've mentioned for the last year or so, that folks who are interested to provide public comment on our next potential model with CMMI and all of those comments that we receive we share with our partners at AHS and the governor's office as they are leading the negotiations on the next model. Last I want to provide an update to you on a request that you made of me last Wednesday. You had asked me to write a note to DEVA and AHS to ask if they had any updates for us regarding availability of Medicaid rate increases or one time funding to address the requests where we have received from our hospitals for their mid-year rate requests. As of this morning I do not have that letter for you. I will keep you updated as the day goes on but I did want to report that out to you. And that is all I have to report unless you have questions. Thank you Susan. So with that I'm going to turn the meeting over to Patrick Rooney to tee things up. Patrick. Good morning Mr. Chair. Can you see my screen. We can. All right. Excellent. So good morning board members stakeholders and members of the public. I want to start by just ensuring Kim you can hear me. Yes thank you. Excellent. Okay. Well thank you everyone for joining us on this sunny second to last day of March. We are here to discuss again the mid-year rate request for Rutland Regional Medical Center. By now we're familiar with the content of the factors that the board shall take into consideration for this process. As Executive Director Barrett alluded to public comment has been open for this process the entire time whether it be specific to Rutland or now UVM and Central Vermont's request for amended budgets for Rutland specifically. We've received as of last night nine overall public comments related in total or in part to Rutland's request. Several of these comments cite both Rutland and UVM Health Network requests so where Rutland was specifically mentioned we made sure to include in this slide page here. You can see some of the participants. We also had several members of the public who either did or did not want their comment shared if they did. Those will be posted and can be found on the GreenMap Care Board website. If they were not then they were just sent to board members as well but we want to acknowledge the receipt of those in this process. A couple of changes from last week. We took another try at trying to flush out the specific inflation factors as it relates to Rutland Regional Medical Center for this amended budget and so we took a stab at trying to segregate some of those and I'll talk a little I'll talk further about that as we make our way through. It felt like the board was having trouble distinguishing which components were one-time components and which components were lasting. And so we'll talk more about that as we get into the slide deck. And then we also added a financial comparison analysis of Rutland versus its state PPS peer group and the Fitch peer groups that we used in the budget process last year. And so we took Rutland's Q1 information across some high level financial indicators to show you where they're at as of Q1 versus their peer group in Vermont at that same stage and then versus the Fitch peer groups as we'll outline later on in slide 20. So trying to provide some alternative perspectives to you to help you feel confident in the decision that you are trying to make today. So by now we know the order of battle here for Rutland Neutral Medical Center's request and the nature of that request. So I'm not going to go into great detail on that. We're very well aware of what this means for Rutland as they've brought forth to us and in several interactions over the last couple of weeks have continued to provide timely information to our request for feedback. So I do want to extend the thanks for them for taking the time to respond to our many requests that have helped us navigate this process over the last couple of weeks. Again citing some of the financial items here. Rutland's projection currently puts them at a net operating loss of 7.6 million dollars. Their estimate for kind of an excess loss this year would be almost 12 million dollars as things currently stand. And then their proposed 9 percent rate increase would bring that operating loss to about break even. However with their current forecast the total loss on margin would still be around 4.5 million. And you can see the different variances that we've put here according to budget and their current projection and their projection with their rate increase. It's all information that you are familiar with to date as this is our third iteration of this discussion. Again just NPR levels where the hospital has historically performed showing the increase that they're experiencing on behalf of that NPR component and then where that would go with the proposed rate increase if approved in full. History of operating margin again a hospital that has reported positive margins most likely not as robust as they would prefer. However as a standalone entity in this environment they've performed relatively well in that regard. Again days cash on hand this does also have within it as we've discussed Medicare advances that are patting those figures the last couple of years but those are beginning to undergo reclamation so that will continue to come down. But overall the organization does have a relatively healthy days cash on hand in comparison to its peers. And again you'll see that in the comparative analysis that we did on slide 20 as we navigate towards that. Rutland's change in charge currently they're in the middle of the pack. We did hear discussion last week about the 2017 negative rate adjustment that was approved by the board. And we've been calling this out all along that as of the fiscal year 22 process that negative 5.1 percent did fall off of this five-year look. So admitting that the five-year look has its strengths and also its weaknesses in that there was that significant adjustment made just a few short years ago. But for the most part Rutland currently falls right in the middle of the pack on change in charge both in the five-year average and five-year median of Vermont hospitals. Taking a look again the five-year and where that approved nine potentially approved nine percent would bring Rutland for historical base increase in 2022 and that would be 12.64 percent which would put them right at the top of their peers on the five-year average and five-year median elevating them in that five-year look. Again that is a there are limits to that five-year look as we know. So take that as you will in providing some context. And then last week we went through some of how Rutland was looking to distribute these rate increases both from a gross and net revenue perspective. So I'm not going to review all of these again but they did provide some analysis for the board based on a board request to see how that was going to be applied to service lines and they also did their own comparison to some of their peer hospitals in the state based on those rates. So slide 17 getting into that inflation component analysis. So what we what we did was we asked Rutland to go back and populate the inflation table that they populated for their fiscal year 2022 budget and that's what you see on the screen here. And so what Rutland did was they factored the increase the percentage increase the dollar value of that increase and how that increase affects the overall operating expense budget. So you can see there that wages and compensation for medical staff represent 11.8 percent of their total operating expense budget for fiscal year 22 and the same goes for these other major inflation factors. Now these are all factors that they did cite in this request and so they are pertinent to this. And then what we what happens is it takes a weighted average based on that percentage increase and that percentage of total operating expenses. So we can see that on average Rutland's fiscal year 2022 budget as it relates to these major categories had an inflation factor of roughly 4.4 percent. And so what we were trying to do was we were trying to show okay that's what they planned for. But with respect to these specific categories what are they now experiencing. So we also asked them to populate based on their projection where they see these items going and how they're impacting that experience that they currently have. And so on the next slide you'll see what they've populated for us. So a pretty significant change in the percentage increase and in the dollar value as opposed to the previous slide. And for the most part the percentage of total operating expense in that middle category there doesn't move materially but there are some changes. And so that's going to affect the weighted average and you can see that the weighted average for these categories comes out at about 10.5 percent. And the Rutland called out some of the one time retention components that are driving specifically those two wages categories. So that got us thinking it seemed like the board was struggling with the thought that a rate request which is going to be built into the base in perpetuity may be covering some items that are one time in nature. And so what we wanted to do was provide a little bit of a different perspective to flush those out and see what the increase is without those one time retention bonuses which I believe we heard from Rutland's leadership they are looking to phase out as they begin to plan for tackling some of the workforce issues that they're coming up against. So even though those retention bonuses were necessary on behalf of leadership to retain their staff in an effort to keep contract staffing as low as possible they are relatively final in nature and they will not be reoccurring. So if the if certain board members were concerned about building in a base increase to Rutland's budget which will remain there forever even as some of these costs come to a close. Perhaps we could provide you with a little different insight and context based on that to help you in your decision. And so the next slide we've done exactly that. We've looked at the inflation percentage increase that they budgeted for and what is being projected and the variances. So you can see that on the far left and again the inflation categories are mirrored to what were on those previous two slides and then the dollar value. And so you can see the difference here when we do the variance to budget in the middle that wages and compensation for non-medical staff are exceeding their budget expectations by 7.1 million. However as we pan to the right those one-time adjustments are making up for a significant amount of that. And as those begin to subside board members may be concerned that any rate increase that they may want to give Rutland is going to stay there and yet these costs are going to go away. So we did some adjustments based on that. And in the adjustments column you can see what that what that unplanned or unanticipated increase looks like without those one-time incentives. And so the total comes from 23.2 million dollars down to 15.3 or a variance of about 8 million dollars. So from budget. So it is still in excess of budget by 8 million dollars the total of those columns. But we wanted to segregate out some of those one-time incentives. And so if you are looking to provide a lower rate increase we hope that helps get to that space where you can provide something for Rutland acknowledging that with as it relates to wages that yes there's about 4.9 million dollars or so combined in those two categories where there's been unanticipated increases. So from budget however that number becomes much smaller because that adjustment actually brings down medical staff lower than what was initially planned. So what we have here across drugs and medical supplies is drugs are coming in a little bit lower but medical supplies are coming in significantly higher from a price-effects perspective. And then of course contract staffing is the largest of the unanticipated components as it relates to these various categories. So hoping that provides some additional perspective to you as you reach your decision today to understand that some of this is one-time decision making and if you feel that the leadership at Rutland needs to essentially own that and it shouldn't be shifted to in perpetuity to ratepayers then we hope that helps you get to your a place of comfort in your decision. So we kind of dovetail this with a comparison of Rutland as of Q1 to its Vermont PPS peers. So there are five other organizations that have a PPS or subset of PPS designation. And so you can see here through Q1 that the peer group is outperforming Rutland. They are also outperforming Rutland on total margin as well. And however when we get down into day's cash on hand you can see that from a reserve perspective Rutland is well in excess of their peer group in the state of Vermont through Q1. And then some of the cash flow items days payable and days receivable. They pay their bills slightly later than their peer group but for cash collection purposes they are slightly under or right on target. And then debt service is significantly in excess of their peer group as of Q1. Now we know things have changed since then as we heard from last week. And then their level of indebtedness is right on point with their peer group. And then when we shift over and compare them to hospitals in northern New England of relative size for that Vermont peer group there and in the Northeast in general which does bring in some much larger organizations but we wanted to spread out the region to capture as many organizations as we could some of relative size some larger some smaller. We can see that from first quarter to those 2019 comparables which are slightly out of date. However Rutland is not quite performing up to that peer group in operating margin but through Q1 and total margin they're meeting that northern New England peer group and they are slightly under their northeast comparison. However still days cash on hand even though we know that 244 has some padding from those Medicare advances they are still in excess of their peer group for northern New England northeast. And then their days payable and receivable they pay their bills slightly later than their peer group but their cash collection is well in excess of their peers in that space and then their debt service coverage again well in excess as of Q1. And you can see that the northern New England hospitals and northeastern hospitals in that peer group carry a higher level of debt than Rutland regional currently does. So that concludes the additions to the analysis here. The next couple of slides really just get at some of the past questions that we've posed to Rutland regional in the answer so there's nothing new in that space and then we have the suggested motion language for the board should you choose to reach your decision today. So with that Mr. Chair I'll turn it back to you and your fellow board members for discussion. Thank you Patrick and I'm going to open it up for to the board to ask questions of either Patrick or of Claudio and Judy. And before I do that Kim if you could swear in Claudio and Judy. Yes. Would you please raise your right hands. Do you swear the testimony. Oh OK. I thought I was muted. Do you swear the testimony you are about to give shall be the truth the whole truth and nothing but the truth to help you God. I do. I do. Thank you. Okay so board members it's now open for comments or questions on the Rutland regional budget. Well quite a quiet group this morning. Go first. Thank you Robin. Sure. So Patrick could you go back to the inflation slide which I think is 19. Oh yeah that's the one. So in terms of the contract staffing I know that the there's been significant pressures related to the traveling staff due to the pandemic and inflation. But I think when I think about that I also think about that as a time limited hopefully expense because I think there's work from Representative Welch's office in terms of concerns around price gouging in that space and I think we're all hoping that the traveler's costs will come back to what was a pre-pandemic level. So when I think about that as an additional one-time expense for me that would mean that the baked in costs would come down to 975 about thousand if taking into consideration if the contract staffing was more at budget which I think would be closer to a 1% rate increase. So I guess my question is so I just speaking for myself and where I am you know I certainly want to thank our staff and I want to thank Claudio and Judy for their very responsive clear testimony and for providing us information as we work through this. I do think this is a tough decision as a mid-year rate increase in particular because it does have unanticipated impacts or anticipated impacts that were not anticipated for employers and for particularly self-insured employers who the rate increase does get passed through since they're self-insured. You know the insurance commercial insurance space I would expect probably to see that you know I would expect to see those in the next rating in the next premium rate review hearings. So there would be a time lag on those but for self-insured employers this would be another economic pressure that was not anticipated and I think everyone has those. Certainly hospitals are seeing that but also other employers and families. So I think where I'm landing is somewhere between denying the rate increase in 1 percent. So I'll just put that out there for discussion. Any other core numbers. Could I respond to that. Yes Judy go ahead. Okay thank you. So I just want to be very clear in our projection in those costs and we have not loaded those costs in at the rates that we were paying at the height of the pandemic. And that is really you can observe that in the inflation increase percent the 124 percent over where we were. We have cut those rates back. They are not at the rates that are above the $200 per hour. They're closer to about $150 per hour. So I just want to be clear that we didn't carry those high costs throughout the projection. And that is why you're not seeing even higher rates there. Thank you for that clarification Judy. And Mr. Chair can I also add to that. Proceed Claudia. You know also we don't anticipate. Although workforce is really our top priority rebuilding our workforce. We don't anticipate being back to pre-pandemic levels for the use of travelers for quite some time. And the trade off is either we have to do what we've seen other health care organizations do and limit or close some beds. Or we have to pay travelers to come in and provide those that staffing until we're able to do that. And there's we're working as we testified previously very hard with the colleges and universities and other pipelines to do this. However that's that's a longer term fix. That's not going to happen you know in the immediate future. Okay other board members. I'll go next. So my take on this kind of broadly is that and I think it might be for all these mid budget adjustments is that I would rather this unfold in the context of the normal budget process as opposed to this ad hoc process unless there's something of a critical critical nature that that needs to be supported. This is a very volatile data environment. I'm noting that your non operating revenues relative to what was in your 22 budget were at 5.5 million and at your projected budget they're down to a negative 6.7 million that's a 12 million dollar swing. And to me I mean that's not necessarily where we're going to end up but those are somewhat tied to the market and are volatile. Whereas in the normal budget process we have the opportunity to the legislature's gone home so we know some things there terms and maybe Medicaid. We have the I'm looking here at my little list of things that you know maybe the travelers will have diminished maybe we'll have the all pair model to maybe we'll have a two year budget process is in something that we'll be discussing this afternoon. So I you know I the thing that caught my eye is your bond covenant and that is one thing I think that needs protection and you as I kind of follow the numbers as best I could you know your your your bond covenant ratio is at 1.4 percent and I think now you're at 1.79 percent coverage. And so I would be open kind of in the same ballpark that Robin is but for different reasons I I would I I think it would be a very very bad event and a long lasting event if that bond covenant was breached and so if they're if a one or 2 percent increase would allow and the numbers I've seen that a 2 percent one would allow you a little over a million dollars additional cushion you know to protect that that bond covenant relationship that makes sense to me but otherwise to me we're you know I mean this is all fee for service for example this rate increases all fee for service whereas in our normal budget process we're trying to diminish fee for service. So as much of this that can be pushed into the 2023 budget process which is right around the corner I mean after this meeting today we're going to be talking about the final version of the guidelines for the 2023 process and and so I want to get to that so that we can see this holistically and but I understand your concern it's very scary to be in the top of something like this you know where I mean for me in my career is nine years as finance commissioner it's scary in these positions and I sympathize and the work that our team has done and your team has done is been very thorough but that's kind of where I'm landing is in the one to 2 percent range. Thank you Tom. Other board members. Hearing none I'll open it up for public comment before we ask for a motion. Is there anyone from the public who wishes to comment. Go ahead. Kevin I have some thoughts but I was waiting for you and Tom to reflect on what you were thinking about this before I responded. So I wasn't sure where you and Tom Walsh did on this. Thanks Jess I don't have any I appreciate the staff's work with it with the the additional information and I appreciate Claudio and Judy and their their working with us and the professionalism they brought their responsiveness but I haven't seen any information that swayed me from what I said last time that this isn't an unprecedented situation a business that does hundreds of millions of dollars of business facing tens of millions of losses isn't unusual and we're moving in healthcare toward capitated or fixed payments and shared risk. And this is this is what shared risk can look like and I worry about Rutland Regional and their ability to weather something like this. And when I with the staff's help and on my own looking at their financial position compared to similar hospitals they're right in that they've done a really good job managing themselves prior to this to be in a position where this looks weatherable. And I'm all the concerns about a mid-cycle increase that Tom and Robin have already said I agree with and I'm hard pressed to find to find a reason to move toward granting any increase. And so that's that's where I am right now that's all. And I guess Jess you you you believe that you have the privilege to hear from all the other board members first. I'm trying to make a decision and it's helpful to hear everybody's perspective. I think this is a really really tough decision and it'll take it lightly and it's helpful to hear where everybody else stands with all the information that we're given. So I don't think it's a privilege. I think it's just I'm trying to understand where everybody stands. So the reason why I didn't comment is I thought that what I would say had already been said by a board member Pellum that I don't support mid-year adjustments but I do have concerns and I don't think that any hospital should be playing chicken with a bond covenant. And that's why I would be supportive of a minimal increase just to tide them over because I think the more appropriate time for the thorough discussion is at the actual budget process. So if I could be convinced as Tom Walsh had just said that my fears of a breakage of a covenant are unfounded, then I would be voting to not give them anything. But I have not reached that point. Okay. Well, I mean, that's really helpful. Excuse me for coughing. I'm just gonna try not to cough when I speak. But so I guess, I appreciate all of the comments. I appreciate all of the thought that our budget team has done and the receptiveness of Rutland to all our additional questions. This actually has been keeping me up at night. Literally my cough and these decisions have been keeping me up at night. Obviously negative margins are not sustainable. Inflation is real. We have to make sure that our hospitals have the resources they need to deliver the care. I'm worried about the summer budgets this summer. I anticipate that these rate requests that we're seeing now are gonna be magnified in the summer through summer budgets because hospitals aren't immune to the inflationary pressures that we're all experiencing. I think where I'm struggling and why it was really helpful to hear everybody's perspective is one, in the timing of these rate increases and two, what types of cost growth, a commercial rate increase should cover? And I think slide nine, the one that is up on the screen right now is really telling. When I look at the unexpected expenses that are driving Rutland's requests, there are a fair amount of them that are one time expenses. $8 million in one time retention bonuses that won't be carried forward. I appreciated Judy's comments about the traveler costs and Claudio's comments about that. The expected travelers costs are gonna continue probably for the next year or so, but I'm not sure that it's gonna, even with a reduced rate, we did hear in the hearing that there's an expectation that those travelers costs will be going down. And the hope is that it's going down. So I'm landing where I don't think it's reasonable to ask commercial rate payers to absorb temporary and one time labor costs and perpetuity through this unplanned mid-year 9% increase in charge that's forever baked into the rate. And in terms of timing of that rate increase, I think when we think about unplanned mid-year adjustments of that of a magnitude of 9%, they're gonna disproportional impact those with the least ability to absorb that blow. If we think about small businesses, they may have 30 days cash on hand if they're lucky and households are living paycheck to paycheck. And so in terms of the timing of a rate increase, who can absorb the blow? And how do we think about those unplanned mid-year rate requests? A lot of conversation has been around reserves and when do we use reserves and who has reserves? I guess in my mind, hospital reserves are there to cover capital investments and one time temporary investments in human capital to retain and support a workforce that qualifies to me as a capital investment. As the slide, one of the slides that Patrick showed, it does suggest that Rutland has sufficient days cash on hand relative to its peers, certainly far more than small businesses and households do. And so, I was helpful to hear what everybody else is thinking. Hey, everything all right? Sorry. If you're not speaking, if you could mute yourself, please. So I can't support, I'm not sure if people can hear me. It looks like 802.238, you need to mute yourself. And Robert Hoffman, you're coming through as well. Please mute yourself. Sorry. I think you're okay. Okay, thank you. So, I guess I can't support a 9% mid-year rate increase based on particularly some of the updated information from Rutland. I can't support temporary and one-time costs baked permanently into rate. I had hoped for news from AHS this morning. I would like to think that there's some federal and state relief dollars available since I think a lot of these one-time workforce expenses are linked to pandemic pressures and there's been considerable federal dollars flowing into the state to relieve some of those pressures. So I'm still optimistic that maybe we'll hear some good news from AHS that there might be some relief dollars here to support this because I recognize these are costs that the hospital is incurring. Just can't bake it into permanent rate and I can't bake it in a mid-year adjustment and have that impact be disproportionately felt by those who don't have the ability to absorb that blow. So where I was curious and wanted to hear more from other board members was at what rate between zero and it sounds like zero and 2%, one and a half or 2% might be supported by the board. And I think that perhaps I could blend there too. I think that probably one and a half to 2% would reflect some of the more permanent increases in inflation-driven expenses that Rutland will carry forward. It will also protect their debt service coverage ratio, which I think is important. And around a one and a half, 2% also would bring Rutland's change in charge actually up to the weighted average increase that all hospitals received in 2022. We recall Rutland actually came in with a lower than average rate request and a very, very conservative budget. So I could probably be convinced that something of that magnitude could be supported, but I'm not sure the juice is worth the squeeze at that point in terms of the transactions and billing issues of putting that into place and it might be better to delay it till budget season. But I don't know. So this is where I was really helpful to hear everybody's perspective. And Jess, it's very helpful to, this is Tom Walsh, it's very helpful to hear yours. And I think you laid things out very nicely. And I still worry, and I don't wanna be the curmudgeon of the bunch, but I still worry that even a one to 2% increase as you outline is going to fall on people with people and organizations with much less in reserve and much more difficulty paying. And I'd rather see this work its way through the usual cycle as the peer group comparison has shown, Rutland Regional is in not great shape, everybody's suffering, but relatively good shape compared to peers. And the direction that we're going with changes in the way healthcare is paid for is to deal with fixed payments and sticking to a budget and sharing risk. And so I find the information informative, but at least for me, not enough to come off of denying this increase. I appreciate how you laid things out. You've said it, the best that I've seen it, but it's still, there's a time and a place for this where we can go through our usual processes and Vermonters, no one to expect it can plan accordingly. The timing of this is very troubling to me. And the troubling, the timing is troubling Tom, but the reality is that inflation is hitting everyone and we can't naively think that this workforce crisis is gonna go away soon. This workforce crisis is gonna take multiple years to address and the bad position that we're in today is that we can't say definitively that Rutland will not fall precipitously enough through their burn of their days cash on hand to trigger a bond covenant. And yet we can't also determine what that proper safety cushion is. And that's what's troubling to me. And I came in with the attitude that no increase is warranted unless it can be proven that the bond covenant would be violated. And I just haven't seen that proof. I'm also, I had hoped as you requested the last time that we would have heard back from our colleagues about what COVID specific relief funds may be available. We still don't have that information and voting for 1%, 5%, what have you, without knowing what may be there specifically for something like this. I think that's a function of this mid-cycle request. The timing is very difficult. We're pushing to get that information, we don't have it yet. So there's a lot of difficult things. And like Jess had said, it's something that's, it's a difficult thing. It's kept me up. I wish we had more information, more clarity on what you had outlined, Kevin, more clarity on what our other government colleagues can bring to bear to be helpful. Before I go to public comment, is there anything else from the board? Yeah, I might wanna just ask Claudio and Judy to comment on this. I mean, the bond covenant, as I understand your, the target ratio is 1.4 and you're 1.7 plus or minus now. And that, that delta between the 1.7, 1.4 is, in my rough calculations, about one and a half million dollars, and that is in the ballpark of a one to 2% increase in rate. But let's just, and just the reason I cited the volatility in your non-operating revenue is that is a negative $12 million swing since the 2022 budget was passed from a plus 5.5 million to a negative 6.7 million. So that is a lot of volatility. I mean, just in the non-operating revenue, there was a, over this period of time since the original budget was passed, there's been a $12 million swing. So 1.5 million is not out of the question. You know, it's not an extreme measure, but let's talk about the consequence to the hospital if you breach that bond covenant. What unfolds from that? So we go into technical default and then we work with our partners, the USDA and TD Bank who hold notes of our debt. And we work through a process that they will prescribe for us. So could that result in the hospital having to pay, having to pay a higher rate on their debt? So we do have a portion of debt that rolls over in 2023. We've got some swaps outstanding. All of these decisions affect our strength going into those negotiations. Thank you. If I may add to that, member Pelham and members of the board, there's something that's in our mind, just as bad or worse than us going into default for bond covenant. And I appreciate your understanding and concern about that. But for us, when you talk about, you know, holding hospitals accountable or sticking to a budget, we can do that in the face of these unprecedented cost increases that we didn't create, we have to react to. The challenge is for us to stick to our budget, what we're trying to avoid for our communities and those we serve is something has to give. And why we came to you with this unprecedented request, mid-year, we don't wanna be here. There's a lot, believe me, I don't wanna be here right now doing this. And I didn't wanna go to our board of business people, a lot of folks that pay these. But the reason that we did this is we don't wanna have to reduce services. And the reason we went mid-year is we can't wait until mid-September to hear your final decision on what ends up in our budget to make some of those adjustments. We will be forced to respond and react to be prudent to try to fend off bond covenants and all those other things sooner rather than later because it takes a lot of time, a lot of effort to do that. And that's what we're trying to avoid. And I'm not saying this to be alarmist or scary, I'm just saying this to be realistic. And once having served my entire 30-plus year career in rural healthcare in Vermont and in Maine and Illinois, I've seen firsthand once you reduce, especially in a rural area like we are, in an underserved and a socioeconomically challenged area, once you reduce or eliminate some of those services with some of these pressures, it is almost impossible to get those back. That's what we're fighting against and that's what we're asking your help for. We don't wanna be in that position. And it's not because we're asleep at the wheel, it's these costs are real, you recognize them. I understand you're in a tough position, but so are we. And we don't wanna, we think that pain is worse than some of the other things. Well, that's our position in this. But Claudia, I appreciate you bringing that up. We share a desire to serve Vermonters, right? And I don't wanna see service lines closed anywhere. On the other end of the spectrum though, looking at individuals, we know the research is quite clear. We probably have family members faced with even a $25 increase and they're out of pocket expense, they don't go to a service line that's open. They don't get their medicine. And so it'd be terrible for a service line to close, but increased out-of-pocket expenses stop people from going, they ration their own care. And so trying to balance this is a very difficult thing. And we share a desire to serve Vermonters and I appreciate you bringing that up. So if I could just add, there's been a lot of focus on using reserves to fund inflation. And we have done that in Rutland. All of those one-time costs have been funded out of our cash reserves. We made that commitment when we made that decision and we've certainly followed through on that. But reserves are also used for things that we're all passionate about, we're all committed. And that's moving from fee for service. And the only reserves that hospitals have are their cash to migrate into those fee for service or those value-based programs. I will tell you, we're trying to make our way in Rutland. When we look at our Medicaid utilization this year, if we were not in value-based care, we'd be about a million dollars above where we are right now. We are getting paid less for our Medicaid utilization in value-based care than we would fee for service. The other piece that we're all worried about is where are the risk corridors going next year? They have been limited. They have been controlled by the good work of you, this board, OneCare. But we are looking at significant increases in those risk thresholds and corridors. The only reserves we have are our cash to make that transition. And so I would ask you to think about the cash on balance sheets, a bit more different broadly, I guess I would say, than just supporting inflation. They're really there to support our transition in this commitment that we have as a state of Vermont, as healthcare providers to move deeper into this value-based payment structure. And before I go to public comment, I just wanna say, Claudio and Judy, that I do think that you're one of the better-run hospitals that I've seen, that I appreciate everything that you've done throughout the pandemic and even before. And I don't believe that any hospital should be in a position where they have to operate at a negative margin. If there is no margin, there is no mission. The problem that we have here is timing and when's the appropriate time? And I realize in my brain, I'm thinking as a former business owner, do you have that harsh impact all at once? Which would be in the normal budget process or do you have it phased in? Anybody that thinks that this pressure on the workforce is going to go away anytime soon is mistaken. It's gonna take years for us to do what we should have been doing a number of years ago. And we knew that there were bottlenecks. We knew that qualified Vermonters who want to become nurses were being not accepted at programs due to some real discrepancies in the pay for faculty and even more importantly, as we're talking with hospitals, the lack of sufficient clinical experience and precepting. So, I don't know what the right answer is here and that's what makes this decision even more troubling. Oftentimes things are very black and white. I think there's a lot of gray here and with that, I'll open it up to public comment. Does any member of the public wish to speak at this time and I'll start with the healthcare advocate, Sam. Thanks so much, Chair McMillan. Sam Pish, Health Policy Analyst Office of the Healthcare Advocate. So the HCA we submitted written comments but I'll just briefly summarize them here. We recognize the current financial position of RMC is partly a reflection of critical investments made in their healthcare workforce, which we support that are related to the ongoing COVID-19 pandemic and beyond. RMC asked the GMCB to make the assumption that rejecting their charge requests will inevitably result in deep cuts to medical service lines. This may be, however, this argument is difficult to accept apps and any meaningful discussion or alternative contingency plans from the hospital as to why this is the case. There are other mechanisms to raise revenue and or cut costs or use reserves. We therefore urge the Green Mountain Care Board to reject the mid-year charge increase requests for Rutland in the interest of short-term and long-term consumer affordability, health insurance market stability and working towards short and longer term state health reform goals, particularly as we consider global budgets. We also share board member concerns about gauging in this type of mid-year process as we move into the annual hospital budget process. We can hold two trues at the same time. We can both command Rutland for the heroic work done during the pandemic as well as investments in their workforce and recognize the charge requests, particularly at the level requested are unsustainable for the state both in the short-term and the long-term. Thank you. Thank you, Sam. Are there other members of the public who wish to speak at this time? Are there other members of the public who wish to offer public comment at this time? Hearing none. Board members, does anyone wish to make a motion? No takers. Shall I do my usual? Thank you, Robin. Sure. You know, I'll just say this is a really tough decision. So I think the motion that I, the motion I will make reflects where I am. And I do want to say that I agree with you, Kevin, that Claudio and Judy are terrific and they've done heroic jobs. And I certainly appreciate the tough spot that they're in right now. But I'm gonna move to deny the rate increase. Is there a second? Second. Is there further discussion? Hearing none and not sure what the outcome of the vote will be, I'll ask Russ McCracken to call the roll. Thanks, Mr. Chair. I will call the roll in alphabetical order. Member Holmes. Yes. Member Lunge. Yes. Chair Mullen. Yes. Member Pelham. No. Member Walsh. Yes. But the record show that it was a four-to-one vote denying the request. Kim, I want to thank you and I understand Joanne will be with us at one o'clock this afternoon. That's correct. Thank you. Thank you. And at this point, Tom, I'm gonna turn the meeting over to Patrick Rooney to discuss guidance for fiscal year 23. Thank you, Mr. Chair. Can you see my screen? We can. Great. Thank you. Before we get started, I do want to do some follow-up with the board on what we just heard. The mid-year budget cycle that we go through when requested is not as formidable as the true budget process. And because of that and some of the circumstances surrounding the current healthcare environment, we've had to kind of pivot quickly and think on our feet and provide perspectives that we probably wouldn't normally provide in that mid-year request. So I'd like to know if the inflation exercise that we went through today and the comparative peer analysis was helpful to the board because if it was, I'm sure there are folks from the UVM Health Network on listening to that discussion today that we should signal that they can expect a similar request as we move towards a discussion on theirs as well, because we have the two hospitals from the network. So if that... Speaking as one board member, Patrick, I would say I believe it was helpful. Okay. I agree very much so. Same here. Also agree. Thank you. All right, thank you. We will make sure that we prepare a similar analysis for the University of Vermont Medical Center and Central Vermont. Okay. Transitioning now to the guidance. Before I start, however, I do want to take this time because we can sometimes wrap up our business relatively quickly, but I wanted to make sure I took the opportunity to thank the team that was involved in bringing this to this point today. And it's my hope that we can land this thing and again, to move on to other works. But I wanted to say specifically a huge thank you to the finance team, Lori, Matt and Flora for their work on this. Russ McCracken, our staff attorney who for better or worse gets embedded with us every time we go through this business. He's been exceptional as always. And some of the members of our extended team this year, Sarah Lindbergh or Jeff Patista from the analytics team, Michelle Sawyer from the ACO team, Michelle Degree who have helped us really round this thing out. And kind of one of the unsung heroes, our administrative assistant, Kara Kreis, who has kept this activity moving forward and keeps that transparent component alive by getting these documents to the internet for consumption by the public. So I want to take that brief moment there, to thank everyone for their work. It's been a very busy month and everyone has taken the time and paid the attention to make sure that we can deliver on behalf of the board. So I wanted to extend my thank you to everyone. And with that, we will move into the discussion here this morning. It is March 30th. This is the third iteration of our discussion in the last three weeks about the 2023 hospital budget guidance. We are hoping to attain a vote here today of approval for that guidance, which as you can see on the screen, next steps would be submissions of the hospital budgets on July 1st. And we are due to, if approved today, we are due to deliver this guidance and supporting documents to the hospitals by tomorrow, March 31st. To date here, public comment received on behalf of Boz. They did submit another one late yesterday after we had already published this slide deck. And also I want to include the HCA in this because some of their comments that they provided last week were also public comments that were built into their questions and contributions for this cycle as well. So recap, as of March 23rd last week, these are the changes that we had proposed to the board last week. I'm not going to go through each one of these on the hospital guidance and dependencies. So, wait a second here, I opened the wrong document. I'll be right back. This is not updated, my apologies. I was getting concerned there. Okay, that's embarrassing. I was wondering why I wasn't seeing the HCA recognition of their public comments and additional questions. So, I apologize. Here we go. Again, as of last week, some of the changes that we made and presented to the board, and this has been a process where we've provided you with the changes and then stepped up to discuss the changes that we've made in the interim. So, these were as of last week. Here we are with the guidance policies. There's really no changes here. Russ had addressed the HCA's contribution to this policy in addition. That was made as of last week. So, their request has been added to that, but that was a change that was already in discussion. So, some of the changes from last week where there was a request to add to section 3b2. I will scroll to that. Here we are, highlighted in green here to add occupancy rate per staff bed and occupancy rate per licensed bed. So, we've added that component in here as well. Section 3d3 on wait times and add to have hospitals discuss and outline the steps to resolve some of the wait times that they've been hearing. So, a minor narrative component asking the hospitals to provide some forward thinking and planning around how they expect to resolve some of those wait times. Section 3e risks and opportunities. There was a request to provide some information for benchmarking around salaries per FTEs per adjusted occupied bed and salary expense to NPR. So, we've gone ahead and added that as you can see here. In the supplemental data monitoring section, we added language and I apologize for the lack of highlight here. So, I'll do it up on the screen. Board Member Lange had asked last week if the HCA's request around Medicare reimbursement ratios was redundant to some of the work that was being put forth in the supplemental data monitoring component. And so, we met with the HCA and reached a very quick conclusion on behalf of Jeff Patista from our analytics team that in fact we could provide the HCA with the information from the data that our analytics team is going to compile for this process. And so, we added language that would outline how it was going to be broken down and that our analytics team would be able to provide those tables to the HCA for use in their analysis. So, we wanted to highlight that that has been eliminated. The HCA agreed with Jeff's assessment. And so, we've been able to eliminate that potential additional request but we wanted to call out some of the language here that captures what the HCA was looking for. So, we made a specific point to add that here. The only other component that we have to add is that the HCA questions were updated as a result of that. They, we did agree that the question around contingency for change in charge or lack of receipt of the charge that they request should remain as a written question. So, the only items that were removed from the HCA's previous submission was that Medicare reimbursement ratio component. The rest of it remains intact and everybody should have received a copy of those updated questions and those are also posted to our webpage. So, the big discussion is going to be around net patient revenue and what that figure should be. And so, we look back at how we approached some of this work last year and ultimately and similarly it came down to providing some options for the board to consider. And so, we wanted to walk through some of those that have been directly discussed or some items that have been alluded to as we've gone through this process. And so, one of the more notable options here is that there be no NPR guidance and the rationale is that the healthcare landscape is too volatile to set some specific NPR guidance in this budget process. However, Board Member Lange was also curious about if that is going to be one of the options for consideration that there be additional components by which the board can attempt to assess and measure that growth. So, while the board may not seek an NPR guidance this year, it shouldn't just be blanket no guidance and there's no capacity to measure the request. So, we worked with our analytics and our legal team to outline some of these and also Board Member Lange. And so, identifying metrics to assess the components of NPR from a patient hospital perspective for affordability and reasonableness is the core of what some of these metrics seek to capture in lieu of NPR guidance growth. So, the indices of price and cost inflation that affect hospitals, provider price index, consumer price index for medical services, measures of consumer affordability, wage growth, CPI for all urban consumers, personal consumption expenditures, ability to achieve state reform goals, compounding annual growth rate in all-parent model of care from 2017, less than or equal to 4.3%, population or demographic data, hospital variation cost and reimbursement and data relative to payments to similar hospitals. So, several of these are already built into the guidance and would further support, in theory, the no explicit outline of NPR guidance from fiscal year 2022. So, that's option number one. Oops. Option number two was proposed by Board Member Pelham, a two-year aggregate guidance of 9%. And the rationale there is the two-year approach will provide flexibility for growth in fiscal year 23 and 24. Excuse me. And it considers the personal income growth outlined in the economic review and revenue forecast update for the state of Vermont that was put out in January. And so, I believe those numbers were 4.7 and 4.6% as outlined in that report for 2023 and 2024. So, 9% would be right around what is being projected for personal income growth, again factoring that affordability component. Option three, and this is one that's been floated out there, but hasn't been directly discussed, but we thought it was prudent to put in here, is the continued alignment with the all-pair model total cost of care growth of not more than 4.3% in 2023. And the rationale there is that it keeps hospital growth in line with the average growth outlined in the five-year APM agreement. The range there is 3.5 to 4.3, going at the higher end to, again, capture some of those circumstances that exist in the healthcare landscape, but still maintaining that linkage to the all-pair model in healthcare reform efforts. And option four is a hybrid of two and three with an aggregated two-year approach of not more than 8.6%, so it'd be two consecutive years of all-pair model total cost of care growth at the high end of 4.3% for 23 and 24. And again, the rationale there would provide flexibility for growth in 23 and 24, that is not explicit to 4.3%, so it carries with it that option number two component of should a hospital feel that they need to grow 6%, then that still gives them some flexibility in the prior year as things begin to normalize again. So it's also still tied to the all-pair model agreement and it still considers the economic review and revenue forecast update for the state of Vermont as it relates to personal income growth. And so again, tying it back to that affordability component that the board always seeks to consider. So a small update to the staff recommendation. We do still feel that the board should establish some sort of MPR growth ceiling based on the majority of the options just presented. We are pulling back on our original consumer producer price figure that we originally discussed. The discussion has evolved since the early stages and there's no appetite for that approach. So we wanna focus on the options that have been provided on the previous slide. So that this does not serve as a distraction. We have cut that from staff recommendation. However, the other recommendations still stand. And that includes at the very bottom here, all of the adjustments and also that we recommend you accept the updated HCA questions from the healthcare advocate as part of this process. And so the couple of items that you would need to vote on today are the NPR FPP growth guidance. Whether or not you set a limit, we need to establish the board's perspective on that. And also the overall acceptance of the budget guidance. So we have motion language for both of those topics. And should we be able to reach that conclusion today? That concludes the presentation taking us to July 1st for submission of budget materials by the state's 14 community hospitals. So with that, Mr. Chair, I'll turn it back over to you and your fellow board members for discussion. Thank you, Patrick. And not to be overhanded with my fellow board members, but if we don't reach conclusion today, we'll be meeting again tomorrow morning at 7.30 because we have the obligation to have this settled by the end of this month and we will meet that obligation. So I'm hopeful that we can settle this today and move forward. I'll start the discussion off by saying that I favor option one, that I don't think that the other options necessarily work. We just made a very tough decision to deny a rate request. But in denying that, I hope that we sent a clear message that this board is gonna be receptive to understanding the pressures that hospitals are seeing in the normal budget process. And we can't turn our heads on the fact that the cost of nursing and other provider pay is not gonna magically just stop. And we have to be prepared for some significant increases in the upcoming budget season to reflect that. If not, we're gonna put hospitals on a death spiral as they chew through all existing reserves or they start making the unconscionable decisions to start to shut down units. And that brings up the topic that wasn't discussed on the slides, but I think Bear is discussing. We received a letter from Vaz asking for a few things. And I just want to say that one of the things that I'm not prepared to cut out of guidance is the information on wait times. To me, we have the triple mission and that triple mission is very clear. It's in our mission statement and everywhere else that it's about controlling cost. It's about access for Vermonters and it's about quality of care. And to me, the most important of those is making sure that Vermonters have access to care. And I think that we are in a situation here where some Vermonters are not receiving timely care. And I think we need to continue to collect that information. And I agree with some of the points that Vaz has made that this may not be the most perfect solution that has been proposed. But I wanna ask our staff attorney, Russ McCracken. If we vote on this and there was continuing dialogue on a better measurement of wait times, could this be amended at a future point in time? And the reason why I asked that is the effective parties that would be doing the work would be the hospitals. And if it was amended, it's because they made a case why there's a better way of doing wait times. So that's why I asked the question, Russ. Under the board's hospital budget rule, the guidance is supposed to be issued by March 31st. It doesn't talk about amendments to the guidance. I think that if there was an amendment that was supported by the hospitals who are submitting the budgets and also by the board, then I'm inclined to say that the board could do that. Thank you, Russ. Those were really my comments on where we're at. Other board members? Sure, I'll go. I support option one as well. And I appreciate all of the additional references to the data that we would use to assess the reasonableness of the budget submissions. The emphasis, I would emphasize that my focus will be on a comparison of the budget requests to the actual experiences in fiscal years 19 through projected 22. And using that data, we can rely on evidence-based reasonableness of the pricing and utilization assumptions in the submitted budget. So I support option number one. And like Kevin, I don't support dropping the wait time information as Kevin referenced, access to care is critical to improving our population's health. And given the really long wait times revealed in the state's report, we need to do better as a state on improving access. And the first step to improving access is monitoring wait times in a consistent and standard way. And so I would support keeping the wait times as is and to the degree that we learn along the way that there may be some better ways. This is a learning process, but I don't think kicking the can down the road is the appropriate step here. So I think that I would support the wait time data collection efforts that are in the budget guidance as written. That's all I have. Thanks, Jess. Other board members? This is Tom Walsh. I also support continuing to monitor wait times as discussed. My experience in other organizations is there's no one measure of wait times that everybody agrees is sound and fit for everyone. It takes multiple measures to include the views from all stakeholders vantage points. I am not familiar with one measure that satisfies everyone. So we'll need to come to terms with that. I think it's an important thing to keep monitoring because like Kevin said, I think access is a key thing. And as I mentioned earlier in this meeting, access is not only a function of is there a place to go, but it's also a function of is it affordable to go? Is it affordable to go there? And so I think guidance regarding NPR growth is important. And I think looking at our existing agreements is also important. That's why I favor option four. I think the upper limit of our existing agreements provides over a two-year period. The 4.3 per year over a two-year period at 8.6 affords a lot of flexibility. An organization could request a 7% increase in year one and a 2.3 the next to help weather some of the concerns people are facing. I'm comforted too by the work the staff has done bringing in the forecasted growth in state GDP and personal income. That 8.6 over two years is nicely aligned with the 9% projected growth in GDP and personal income. That gives me some reassurance on the affordability front. So I'm in I'm landing on option four at the moment. Thank you Tom. Other board members. Yeah I'll step in here. I having been the author of option number two I would fully can fully can see that option number four is a pretty close call and I can land or you know I think I'm landing around option four as well. I think what it does is give it does put a lid on our you know on our expectations for revenue growth and the cost growth but at the same time spreads it over a two-year period and allows hospitals to take that cumulative amount and work with it. I mean we might have some hospitals out there that haven't been as badly treated you know by the COVID in situation and are doing quite well and might want a two or 3% in year one and the remaining amount in year two. So it still has constraint but it has flexibility. And as the note at the bottom of option one says we live in a volatile environment. This does give some order to it relative to option one. I'm just concerned that you know here we are an entity pursuing health care reform that talks a lot about capitation and fixed perspective payments and global budgeting kind of containment vessels for health care expenditures. And at the same time we have a budget process for hospitals you know that doesn't set a target. And I fear that at least I fear that I kind of have a feeling for what we would get with this process. It takes me back to Dr. Brumsted when in his appeal I think to the 2021 budget where basically was pegging the argument to very medical inflation amounts. And as we can see in the current application where things are being tied to inflation rates that are nine or 10% a year. I worry that we're going to get from hospitals a wish list in terms of a response to a budget process as opposed to a reasonable budget process that is you know that is as Tom as the other Tom was saying kind of balanced and integrated with what's actually going on on the street and you know in the homes of Vermonters. I think we have to do everything we can to live in that three and a half to four and a half percent of the world and do it in a reasonable way. But to take kind of in an un you know an approach that basically doesn't give some fiscal guidance and discipline to the process is a potential rest it could work out fine but it's a potential recipe for not working out fine. I do think that the metrics that are there are helpful and whether it's option four option one those metrics are helpful but I think we need some discipline in the process from the get-go and so I would land on option four. Thank you Tom. Robin did you want to offer any comments before I go to public comment. Sure. This is a tough one for me. I recognize what you Kevin and Jess are saying related to the volatility and that picking a target this year we could be picking a target that is unrealistic and that we won't stick to. I think you know we could see that last year in our in our process we because again of the uncertainty and the volatility we kind of stuck with the target that we had been going with. And but then approved budgets that were above that to recognize the circumstances of the hospitals and the current status of COVID. But I think even so I think I would where I'm landing is I would prefer to pick a target and then if that target turns out to not be realistic given the circumstances on the ground you know I think we've shown openness to being realistic about that regardless of the target that we set. But given that in my mind the purpose of having a target is to really signal a longer term commitment I think I'm landing on having a target. In terms of what target I appreciate the options because I think they do give us a range to work within. And in thinking about a one year versus two year I look back at earlier in the pandemic when we attempted to do a two year target with this idea that hospitals could kind of balance it over two years. I thought that was a good effort and a good idea. Although in reality I think we didn't especially stick with that in the end the second year. Again we were in the middle of a pandemic circumstances had changed from where we had hoped they would be when we approved that. So I do think there's some risk there with the two year target is that we're just setting ourselves up to not follow it also. But with that said I'm willing to give it another shot I think. So I'm talking myself around to option 4. Okay before I open it up to public comment does any board member wish to offer any more comments. Actually just have a question for those of you in support of option 4. For that to work the expectation would be that hospitals are planning over a two year period. And so I'm wondering if you're also then asking for a two year budget submission or just a one year budget submission. And then in the following year the idea would be the board would hold them to the two year target. The legal question on the statutory language is an annual budget. So again I'll go to legal for a discussion on that. It has to be a one year budget submission and the board will establish annually the budgets for the hospitals. So the target is aggregating two one year submissions. And I'll just say for me it is consistent with my sort of conceptual idea of a target is setting a longer term kind of vision. So recognizing that we still need to make the decision each year the hospitals still need to submit each year just gives a little bit more of an idea of where I'm hoping we will stick in the next two years. Agreed. That's that has been my understanding that it would be a yearly budget submission and approval but having a long longer range plan in mind I think is wise. And having being out front about it and allowing the flexibility in planning. They may an organization may submit a one year but if they are aware of what we're thinking about the two year period I think it's more flexible. Okay unless the board member has further comment I'm going to open it up to the public for comment. And does any member of the public wish to comment at this time and I'm going to call on Jeff Thiemann first. Great good morning. Thank you Chair Mullen. So I just want to start by thanking the board for reviewing our two letters that we we submitted for the record in public comment which I think suggested fairly minor adjustments to simplify the guidance and and with regard to wait times to look at that in a careful and collaborative way. You know in fact yesterday's letter or following some feedback we heard just this week from our chief medical officers was a suggestion from me and the group I represent to sit down and do this together. So I'm a little puzzled as to why that offer would just kind of be roundly rejected. It should be really clear that we were not trying to get out of reporting wait times or managing this issue or looking at it. And in fact if you heard me speak along with many of our members at a press conference we hosted on this issue last month we openly and readily acknowledged the need to look at wait times and the importance of doing so in order for Vermonters to get the care they need when and where they need it. And then just yesterday in the letter kind of you know repeated that in a kind offer I think to work together on this instead of rush into a new data mandate. So I just have to say it's a little disappointing to that the board doesn't appear to be hearing us on that and instead moving forward with a new mandate when we could spend even a small amount of time talking with chief medical officers and data experts and wait times experts and others to measure this in a way that's productive for Vermonters and hospitals alike but not burdensome or or wasteful or punitive or ultimately unhelpful. For example different hospitals have different abilities to collect this information in a consistent way and that could use some further discussion which again we're willing to engage in as I said in the letter. Also to echo some of the feedback we heard from chief medical officers we have not heard a way to manage the issue of adjusting the data collection for severity of illness or urgency of appointments which is a really important point. Another important one is that wait times are a single metric outcomes are another and perhaps an even more important one. And as all of you know well Vermont consistently scores highly on outcomes relative to other states regionally and nationally. So again just plenty more reason to be thoughtful and careful and take even a small amount of time here to look at these issues together and a little more carefully before rushing into a new mandate. We also know that DFR the Department of Financial Regulation is going before Senate Health and Welfare on this issue I think tomorrow and don't know what that might result. Don't know where that might go and I worry about yet another or possibly a duplicative or even conflicting mandate. Finally it's also disappointing not to be heard here for another reason which is that this board I think has kindly many times paid lip service to thanking hospitals for their service and their contribution throughout the pandemic and acknowledging the workforce challenge we faced during and now in the phase that we're in but then not really acting in accordance with those thoughts to streamline the guidance or limit new mandates especially ones that could clearly use some further thought and consideration. So again we fully support the notion and the importance of looking at this data. It's important for Vermonters. It's important to hospitals which are mission-based organizations and I think that would just repeat my request that we do that instead of rushing a new mandate into the guidance which has already not which has already been significantly expanded and I think Mike might comment on that but has not been streamlined or simplified or diminished in any way. And then lastly just to make one point from a previous discussion I would not want to speak for the agency of human services on this but the only federal or state money I'm aware of to support ongoing workforce challenges first of all has to be totally COVID related not just workforce related but literally related to treating COVID patients and staffing shortages related to that and even those dollars as I understand it and any supported opportunities are already completely exhausted. So I will stop there and thank the board as always for hearing our comments. Thank you Jeff and I'll just repeat what I said earlier that I think that we did listen to what you said in your letter. I don't want to get into a back and forth here but I agree with you that the conversation has to continue on the proper way to measure wait times. And that's why I asked the question of legal on whether or not if we could come up with an agreement with you in further conversations that we could go back to and change this guidance. The rule says that we have to adopt this guidance by March 31st and we're going to meet that rule and we're not going to leave it empty so that something could fall apart and nothing would be accessed. I agree with you that DFR is in the legislature but the timing of when they will have that information is in the future and this is a real problem today. And that's why I feel it's important that we have language in here but Jeff I'm willing to work with you to come up with what's even better language if we can start that process and make that happen. So that's my commitment to you. Well so thank you Kevin. I'm not being an expert on what's possible in terms of changing language. I would just say that if there is any opportunity as we move forward to identify better or more streamlined ways to do that we certainly welcome that conversation. Thanks. As with the board thank you Jeff. Next I'm going to go to Dean French. Chairman if it's OK I'll defer to Mike Del Treco. Certainly Mike. Sure. First of all thanks for all the work that's going on here today. My comments are a little difficult to come by this morning. I'm slightly perplexed in this year's process. We've had two years where we focused on streamlining efforts to really focus on those items that impact hospital budget decision making. There are two items that in our last comment around ACO data collection and around the supplemental data requests that may or may not apply to all hospitals to ask all hospitals to answer questions around market share demographics and or variation that they that that is difficult to come by for them is an interesting new new request. So this is kind of how this year worked. The board met the board added new items based on the conversation. Vaas commented you'd certainly discuss some of those things but very little or no action was taken and maybe that's intentional. But I'd love to understand sort of some of that logic because we spent a lot of time sort of analyzing understanding the guidance. We spent a lot of time with our hospital groups from CMO's CNO's to CFO's on what works what doesn't work how to really make sure that we are good stewards of Vermonters resources and all of the things that we all talk about. So that's why I open with I'm a little perplexed but I'll stop there and and and hear your comments. Thank you. So my comments would be quite simply Mike that the status quo is not working. That we recognize that and we can't just allow for unsustainable movement to occur in that the board is willing to work with you to come up with the best measurements of wait times. But when it comes to wait times we take it very seriously and when it comes to health care reform efforts we take it seriously and that's why the ACO information is is there. And you know we're at a point in time where we are trying to figure out what's next in our negotiations with Washington and where we go as a state. And so it's imperative that that information be available to the board and I don't think it's too much to ask. So so you know just just to just to comment. I don't think we're for the status quo either and I agree with that completely. So I I I think in order for any project or process to move forward if we're going to do with the same financing we will have large problems on our hands. I think one of the challenges that I see when I look and listen to these conversations is an inflationary target that's pegged to state growth. Our state growth is flat and stagnant. We have an economic crisis and that we shouldn't tie the Vermont hospital growth rate to. So I agree with all of the reform conversations. I agree with outcomes. I agree with understanding information. But I don't understand how decisions are made. It's not clear how all of these decisions impact hospital budget of hospital budgets going forward. And I'll stop there. Thank you. Thank you, Mike. Next I'll turn to Ham Davis. Ham Davis, are you there if you're speaking? You're on mute. I'm sorry, Kevin. Can you hear me now? We can. OK, thank you. Sorry about that. And there's really two questions here. One is which option you want on the NPR kind of caps. And the second one is on the wait times. On the caps, I can't see any connection to reality to this discussion. If you look at the system and it's been doing this for 15 years, the problem at UBMC is 50% of the whole system. And it is its huge problem is that it can't process all of the traffic that it's going to get. So whatever cap you put on there has got nothing to do. They're going to just have to get all the more. They're going to have to get people through there faster, not slower. So that question. So for 50% of the system, the option one is the only one that means anything. Although even that doesn't mean very much because the real connection to cost, as far as volume is concerned, is basically captured in the commercial ask. So I think you can put in option one, two, three or four. You can add them together. You can have all the options. What UBM will do is they will get people through their places as fast as they can. And it probably won't be fast enough. And the faster they get it through, the more money they're going to think it's going to cost. That just seems to me obvious. If we get to the question of, on the other hand, in the smaller hospital, we've got a majority of this state, critical access hospitals. Those hospitals are going to get every patient in the door that they can. There's nobody is going to go to a hospital that doesn't want to go to a hospital. And the critical access hospitals are essentially going to do exactly what UBM is doing. Their problem has been to get enough revenue, not to get enough volume. And so in order to do that, they're just going to take all the people they can. So you can talk all you want about these options. They don't mean a thing. The second thing is on the wait times, the wait times is really, really important here. And it's great that the Green Mountain Care Board is really concerned about that. But it's a fantasy to think that the Green Mountain Care Board can do anything about wait times. What are you going to do? Can you get more people in there? Can you hire more doctors? You can't do any of that. So as far as I'm concerned, what we're getting here is a huge amount of unreality. Thank you, Ham.  Is that from earlier or did you mention something? I did have, I appreciate the board's budget guidance. Just a couple of quick thoughts as we talk about these things. Wait times, I agree with the commentary from Vaz as a member of Vaz and the challenge of measuring it. I think importantly for some of the hospitals in the state, like mine, we have pluralistic medical staffs, meaning a fair number of our medical staff are independent physicians in our health service area. And it's unclear to me when we talk about wait times, whether you're asking me to try to measure the wait times into independent private practices. And if you're not, then what are we actually accomplishing? I have two independent dermatologists in town. I don't employ any. One of the longest wait times in the study that the doctor did was under dermatology. I have independent surgeons. So it feels to me like we're going to go through this exercise of measurement of hospital-employed providers, but it doesn't actually give us a full picture of what access to care is across the health service area. And so to me, there should be a pause and a serious conversation about what we're trying to accomplish. And then, and I have one other thing, and that's on the options. And I would just say this, the net patient revenue cap for certain markets is challenging when we look at access to care and the need to get people access to specialists in health service areas. I have an aging demographic. I have a growing county in health service area, not a flat county, 20% growth in over the age of 65. I'm in the middle of my community needs assessment right now. And that's going to inform what service lines this facility needs to build out to meet the needs of the community over the next five to 10 years. Net patient revenue caps make it very difficult to thoughtfully plan and invest in service line development to meet the needs of the community. And those investments will help offload the hospital 25 miles to myself for things that could be being managed in a community hospital well and in a high quality way. But this process we go through makes it very difficult to think strategically and thoughtfully about those directions. So I think, you know, I liked some of the elements of this conversation because I think we were getting there with the two year discussion. But have that in your mind as we think through these things because I think part of our problem right now is years of net patient revenue caps that were set, I think in 2014 or 16, reflect a market reality that existed then and have locked us into it. And we're not able to be flexible enough to meet the needs of our community. Hence, you know, the ever demanding need for the tertiary medical center to grow while you're having your community hospitals contract. So I'll stop there and I don't know if you have a comment or not. Thanks guys. Thank you Dean. Is there any other member of the public who wishes to offer comment at this time? And I see a hand from Mark Stanislaus. Hi, chair. Thank you for this opportunity. These are more just thoughts to consider as we think about how we think about evaluating the 23 budget process. And, you know, I'm probably speaking more from an individual with 25 years plus experience in health care and a resident of St. Albans, Vermont, more than an employee of the health network. But I think we need to ground ourselves in reality.  But a challenge for me in all of this guidance and like, I'm not getting into the wait time stuff. I'm just going on my 25 plus years of experience in health care is our evaluation is budget to budget. Is really not going to exist in the 23 budget cycle. We are facing a once in a 30 year inflation experience. I don't know what that means for all of us as a group, how we navigate through this. But I would just ask the board to have that in their thought process, whatever they decide to do today, a once in a 30 year experience. So I don't know how we put that in context of laying out a two year guidance candidly. Okay. But I would say it would be difficult to do that. Understanding that we do need, that we do get another slice of this conversation 12 months down the road. Okay. And, and I would put out there for some context from this morning conversation. Once again, I'm relying on my 25 years plus experience, probably 50 plus conversations with rating in season, how they view hospitals financial sustainability. Given the reality of what we're facing today in, in, in the, in the certainty that the FY 22 budget column doesn't really mean much anymore. Okay. I think we're going to be presented with some hospitals coming in with say, how do we deal with financial survival in this next budget cycle? Okay. And so I don't know what that does to wait times. I don't know what that does to two years down the road. But when you think about bond covenants and those, and those outside grading scores on truly what your financial sustainability is, I just worry it that you're going to see hospitals coming in and they're going to be dealing with financial survival. I think you heard Claude, you'll speak to that some of the tough decisions and they need the lead time. So I don't know how that gets factors into all this guidance. And it's probably just more future thinking of how we need to think about how we go through the conversations. But I thought that I would just put this out to this group. You know, so the takeaways is we are in a 30 year cycle here. Hopefully it's once in a 30 year cycle and it starts to come back to whatever the more normal is in any comparison to the 22 budget. I'm not sure what that's going to be worth. So take that for what it's worth. I realize that you need to pass something. You don't have a difficult job working with today or tomorrow morning at 7 a.m. or 7 30. But the most flexibility that you could get into this guidance to at least give the hospitals like, I mean, I just can't help but saying if a hospital is concerned about financial sustainability, I don't know if they care about access wait times right then. You know, I'm not saying it's not important and it's not valuable and and and but so I just think in this cycle there was a cycle a couple years ago that the Green Mountain Care Board really streamlined the guidance. So that's not any of these options, but it's just I just don't know how we deal with these unprecedented times going into a budget cycle and then picking whatever this percentage is to be a comparison to a column that really isn't going to face reality, acknowledging that the board has been open to listen to all the conversations and they do balance many other considerations that even aren't in the guidance. So there's probably no value of any of my comments to this guidance today. So I appreciate your patience, but you know, these are the realities that I think that we're all going to be facing as we as we look towards with July 1st and the discussions in August. Thank you for your comments Mark and I wish I was as optimistic as you that this really is only a quarter century inflationary spiral, but I see this as even worse than what I've lived through in the late 70s, early 80s and it's very depressing when you think about our most vulnerable citizens that are having to deal with going to the grocery store and paying twice as much for their groceries as what they were paying for last year and seeing in one season heating oil double in price and I worry so much about our seniors who are on fixed incomes and it's a bad place that we all have to get through together and we will get through it. We have been through these times in history before and we've always come out of them on the other end and let's hope we do the same. Is there other public comment? Kevin may I just make a comment about the work wait times? Some of the topics that came up? Sure. I just wanted to clarify, we are only asking for wait time data for hospital owned practices. We're not asking for hospitals to go out and reach out to independent practices in their communities. That data is really important. That's one of the reasons that DFR is going to be carrying the wait time monitoring going forward. They have capacity and jurisdiction that through their surprise billing authority there. I just want to say that workforce has been a common theme and the pressures of workforce have been a common theme and data on wait times could potentially support some of the requests that hospitals will be making around workforce and around adding to workforce to alleviate access problems and wait times. In my mind I just want to understand access and you know the operational processes and the workforce pressures that are under the hospitals control but secondly I think it can support potentially needed additions to hospital teams to alleviate workforce pressure so that data would be supportive of those requests. That's the relevance to the hospital budget process. Is there any other public comment? Is there any other public comment? If not I'm going to throw it back to the board and does any board member wish to make any motion at this time whether it's a single motion or a compound motion? So I had a thought about the wait times and my apologies I did meant mean to talk about that before but I was really trying to figure out where I was landing on the NPR options so I was wondering if potentially in the section of the and maybe Patrick you could go to the wait times language and the guidance because certainly to your point earlier Kevin in response to Jeff's comment I was not hearing it as I was not hearing the discussion as a lack of interest or willingness to work together to figure out what the right collection was but simply having language in the guidance was necessary given that we have to approve it today or tomorrow. So I wonder if it would make sense and this is really I think a question both for board members interest in this but also for Russ in terms of thinking through the rule pieces to add into as which could be a lead or could be after the language that's there that board staff and will work with stakeholders which I would include you know vahs or individual hospitals and the HCA we I don't think we need to be that specific but we could be to refine the wait times metrics considered to moving forward and the board reserves the ability to amend the requirements based on the outcome of that discussion just to include sort of that process that we've been talking about in the guidance itself to signal that piece and add context. I think that is helpful Robin and I was playing with some language in my own mind about how to do that and also to keep in line with our rule so Russ is this type of language appropriate? I think we can I think we can include language along those lines I know that we have the rule that calls for the guidance to be completed by March 31st definitely a part of that is to allow hospitals sufficient time with the guidance and the reporting manual to complete their submissions in advance of the summer submission date given that here we're certainly working with the hospitals and to address hospital concerns I I think that language could be included okay would it be appropriate to take a 15 minute bio break and ask Russ and Robin to work on some language anybody object to that okay I'm going to put the meeting in recess to 1140 excuse me 1045 and we'll resume at 1045 Kara if you could put a note up on the screen letting everyone know that the meeting will resume at 1045 thank you yes why don't you give me a call yeah I'll give you a call in two minutes if that's all right yes perfect okay I'm going to call this meeting back to order it's 1045 and Robin if you could report on the results of your work with Russ sure so what Russ and I came up with that we would suggest is that section D wait times would start with the following language the board staff and up to two board members will establish a working group to include hospitals, VAAS and other interested parties to determine by May 2nd which is the Monday 2022 appropriate wait time metrics that hospitals shall submit as part of the fiscal year 23 budget process if the work group is unable to determine appropriate metrics the hospitals shall report the following and then it would go into the existing language and then after the existing language there would be a sentence that read in each case hospital shall outline steps to resolve wait times so I think we'd take out the green and make it at its own sentence so Robin I think that's a great start I would ask for a friendly insertion of language to see why it is or isn't appropriate but I noticed that you said and interested parties and I was just hopeful that we could specifically state DFR since they're going to be working on this in the future and it's good to have the continuum on the wait times and presence and also the health care advocate sure is that a motion on your part Robin yes is there a second I'll second it discussion from the board I just wanted to note the date so Russ and I thought may second because we wanted to give the working group some time to enough time to work through its process but our concern about pushing it out too far was that then the hospitals wouldn't have enough time to realistically respond to the question so that was what we were trying to balance with that may second date and there may be other people may have ideas about whether that's the right balance and I'm certainly open to hearing that that was our shot. Is there any board member that wishes to offer further discussion as it relates to the motion in front of us concerning wait times if not Robin maybe you could read it one more time since my shorthand is not good sure the board staff and up to two board members will establish a work group to include hospitals DFR the health care advocate and other interested parties to determine by May 2nd 2022 appropriate wait time metrics that hospitals shall submit as part of the fiscal year 2023 budget process if the work group is unable to determine appropriate metrics the hospitals shall report the following for each hospital owned practiced through the end of the existing language double I and then triple I would be struck and in its place would be in each case hospital shall outline steps to resolve wait times. Is there further discussion on that if not all those in favor of the motion please signify it by saying aye. Any opposed please signify by saying nay. Board members who have a desire to serve on this group please email me or text me if I don't get any email or texts for volunteers and everyone's hand will be considered raised. So with that Robin do you have a motion that you wish to make on NPR. Yes. But before I get there can I just respond a little bit on the supplemental data in the value-based care language. So I did appreciate and I apologize I didn't do this earlier but I did appreciate getting VOS's suggestions on other components of the guidance. I did want to just respond to the various comments around streamlining I certainly I think I was pretty clear in the last couple of years that I supported streamlining the guidance from the pre-pandemic guidance because of the pandemic. I think however given where we are currently at with the pandemic we need to start looking forward to how to ensure that the guidance again starts to look at issues beyond the financial. Prior to the pandemic I think I advocated as did other board members it was certainly not just me to ensure that we were looking at quality for example to look at the community needs assessments and we had had a component there that gave those sorts of context because certainly the hospitals bring in some of that information sometimes in their narratives so that we are having the community context and the non-financial context when making the financial decisions and I do think that's an important context without which quite frankly I think it makes it harder for the hospitals to tell their story. So for me it was important to continue our work trying to align across regulatory processes which is something which are regulated entities across the board have encouraged including hospitals and particularly with the supplemental data request. I certainly understand that not all hospitals may have fully established answers to these questions but VOS was supportive of meaningfully engaging in hospital sustainability planning as part of the legislative process and in fact asked for language in S-285 about meaningful engagement. So similarly I think the shoes on both feet here so certainly we will hold ourselves accountable to meaningfully engage VOS and we would expect hospitals to meaningfully engage as well and to me the language around the supplemental data is the beginning of that meaningful engagement. I think that information is necessary for us to understand how to move forward with more fixed payments and changes to the regulatory process in the future and hearing individual hospitals perspective on that is important to me at least. So that's why I appreciated but didn't suggest making that change to that section and I think Kevin to your point earlier as we move forward with the all-pair model we also need to understand where hospitals are at with value-based care understanding that they have been dealing with a pandemic and the answer might be there's a lot of things that have been put on hold. We're just turning back to it and we're thinking forward about where to go. So I would expect certainly that during the pandemic that has not been top of mind and not the work that needed to happen but I do think it's important for us to be forward-looking. So I just wanted to address sort of my thinking around those two pieces because I do think it's important to share. Thank you very much Robin. Did you want to make a motion at this point in time? Sure. So I would move for the fiscal year 2023 hospital budget review process the board established a net patient revenue fixed perspective payment growth guidance of up to 4.3 percent over each hospital's fiscal year 2022 approved budget and up to 4.3 percent over each hospital's fiscal year 2023 budget to provide two-year guidance for hospitals and that may not be quite right so it might be helpful for me to actually about- Could you put up the slide with the options on them? Yeah, sorry. I should ask for that first before I attempted to do this on the fly. Okay. So I'm and actually I may need what this might be cleaner if I actually just spend five minutes on the phone with Russ to make sure that I don't screw up this motion language because it's a little bit more complicated than long. And I apologize I didn't do that before but or Russ if you have a suggestion off the top of your head that would be helpful. And if you need the five minutes Russ just let me know. Robin maybe let's just speak briefly on the phone. Alright we will be right back. I'm going to put the meeting in recess till eleven o'clock. See everybody at eleven. Welcome back everyone do we have Tom Pelham with us Tom are you there? I am. Thank you and Jess are you there? I am. Robin and Tom W. So Robin do you have a motion at this time? I do I'll withdraw the previous attempt and move that we and I'm going to do the easy way here adopt option four on slide nine which establishes an NPR FPP growth of no more than an aggregated 8.6 percent fiscal year 23 and 24 that gives staff the flexibility of making sure that they can report Smith the guidance document itself. Okay is there a second? Second. Been seconded by Tom Pelham discussion from the board if not Russ if you could call the roll. Great thank you I'll call the roll. Member Holmes. No. Member Lunge. Yes. Member Pelham. Yes. Chair Mullen. No. The motion carries three to two and option four will be the NPR. Patrick are there any other open points of discussion now in either the board documents or the slides? Aside from the board's approval of the overall guidance I do not believe so. Okay Robin are you prepared to make a motion at this time? I am. I do think there's one I would put it in the realm of typographical fix which is Patrick if you could go to the data supplemental data section there's a lead-in sentence below are the iterations of rec by staff refiners requested that I think should be struck. I think that was I know from the staff so I think that's you know a typo fix so but I'm going to. Patrick are you going to strongly object to that being stricken? I am not but Robin is it in the market share reimbursement or demographic report? No it's above both so if you look under age. Right there. Okay. Yes. Yes we will remove that. Okay. So for your 23 hospital review process I move the Green Mountain Care Board approves the hospital budget guidance as presented to and amended by the board by presented by the board staff and amended during this meeting to be effective March 31st 2022. Is there a second? Second. Is there further discussion from the board? Yeah I just have I would like to make a couple of comments. I think this is probably the quick place to do it. I had I kind of view our reform effort as kind of being a stool with three legs. I guess that's a Vermont analogy that used to work pretty well and the first is hospital sustainability and I think you know that is in process and hopefully will be successful at the legislature and I have great appreciation for her work on that with Elena and her team. So that's one leg. The other is the conversion of fee-for-service to true fixed prospective payments and here I want to note that in our last budget year and the payer mix table as that was in the guidance that if you did the math you found that for commercial payers less than 2% of their payments in hospitals was true was any kind of fixed prospective payment not to say true fixed prospective payment and so I would just like to emphasize what Don George and I'm very glad to see this in his letter to us yesterday where he says we must turn determinately toward value-based payments in global hospital budgets to think more holistically about patient health rather than incentivizing volume by paying for each service individually and so for me if you follow the money there's not a lot of commercial activity in that element of reform but hopefully you know and I had some conversations with Patrick about trying to beef that up somehow in the guidelines and it just didn't work and I think this is in line with Robbins talking about regulatory alignment that we have hospitals saying they want to do it and we have commercial payers saying they want to do it but it's not getting done and so that's one point and the other is the third leg to me is the cost shift and I just want to note that and not that I fully understand this year in the state budget process but I note that in terms of the e-board and house-passed budget so for the emergency board recommendations of the house-passed budget that there's a reduction in the amount of Medicaid global commitment of about $20 million and I don't know whether that is a choice that's being made or whether it's a restriction of global commitment waiver but I would ask that in the near term that we get Diva before the board so they can explain to us what the process is that is used in setting these reimbursement rates because if there is a $20 million to $20 million cut in the 2023 budget that's the cost shift and we got to call it out if there's flexibility there and I don't know whether there is or not but I'd like to have Diva before us to explain the process of their recommendation to the emergency board and as it carries through the legislative process so that's those two areas are important to me and I think we're getting incredibly strong on one but there's flexibility is kind of languishing hopefully we make progress with Medicare on reconciliation and the cost shift is just an open wound in my view which even if we're successful on the hospital sustainability it's the cost shift that can suck the vitality out of that so thank you for your time Thank you Tom Is there any further discussion from the board if not Russ if you could call the roll Member Holmes Yes Member Lunge Yes Member Appellum Member Walsh Yes And Chair Mullen Yes Let the record show the motion passed unanimously Patrick do you have anything else for us on guidance I do not know Thank you for your time this morning Thank you and thank you for the staff's hard work on these issues Mike Barber I know your schedule to go later today do you want to stick to that schedule or would you like to since we have some time before noon to have that discussion on CON thresholds now Whatever your preference is Mr. Chair I could do it now or I could see if there's time at the end of the day My preference is we might be fresher if you do it now Sure just give me a minute to bring up the materials While you're bringing up the materials I see a hand up from Jeff team and Jeff I'll recognize you at this time Yeah Mr. Chair I would just maybe ask that this still happen later today I know that Devin Green on my team wanted to participate and cannot right now and it was scheduled to be discussed this afternoon not right now That is fine we will adjourn this meeting until one o'clock this afternoon and proceed at that time Thank you everyone have a good lunch and maybe get some fresh air