Good afternoon and welcome to the Green Mountain Care Board. My name is Kevin Mullin, chair of the board. Happy St. Patrick's Day everyone. The first item on the agenda is the executive director's report, Susan Barrett. Yes, and happy St. Patrick's Day to all. And I just have a couple of scheduling updates and some reminders on public comments. I'll start with the scheduling, just a reminder that this evening the board will be the primary care advisory group, a technical advisory group of the board will be meeting at 5 p.m. And that meeting information is on our website, public is welcome to attend as well. And then just in terms of public comment, we still are accepting public comment on a potential next agreement with the federal government. And we will share those comments with our partners at AHS as they will be leading that effort on that potential next agreement. I apologize for the whining dog in the background. And the Patrick Rooney will be going over some of the public comment that we received for the hospital budget guidance, but we continue to accept public comment on that as well. So with that, I'll turn it back to you, Mr. Chair. Thank you, Susan. The next item on the agenda are the minutes of Wednesday, March 10th. Is there a motion? So moved. Second. It's been moved in second to approve the minutes of Wednesday, March 10th, without any additions, deletions or corrections. Is there any further discussion? Hearing none, all those in favor of the motion signify by saying aye. Aye. Aye. Those opposed, signify by saying nay. Let the record show the minutes were approved unanimously. And with that, we're gonna turn the meeting over to the health system finance team led by Patrick Rooney as we move through and start to make decisions on this year's hospital budget guidance. So Patrick. Thank you, Mr. Chair. Good afternoon. Good afternoon board and members of the public and stakeholders, happy St. Patrick's Day. We're all Irish today. I apologize for no green. My wife turned down a green suit a couple of years ago and I've been living with a shame ever since. So wearing my lucky wedding day tie instead. Okay. So we're gonna kick off today, March 17th with the second meeting in what is it? What is three meeting hold? I will move this to reading view for everyone. And if we could get everyone who's not speaking to put themselves on mute, there was a little bit of a feedback there. So maybe that will correct that. Thank you, Mr. Chair. So we're gonna start off with a similar look as we did last meeting as we sit here in meeting number two of the three meetings we have set forth. These are not by all means concrete at this stage and we will adjust these as needed if we move through today and we need another meeting on top of the March 24th hold that we currently have. So this is the roadmap for now. It could change based on today's discussion. And picking up what we left off from last week, as Susan mentioned, we did receive some public comment and we wanted to acknowledge the receipt of those from the folks on the screen. Dale Hackett, different medical center, UVM Health Network, VOS and the healthcare advocate. And we'll touch on a couple of these as we go through. There was some, we wanted to acknowledge some of these items specifically VOS. We wanted to, or I wanted to apologize for not mentioning this at the last meeting, but they had sent a letter to the Greenmount Care Board on I believe it's February 5th, asking for a suspended or significantly stripped down budget process and their letter received on March 15th reinforced the feeling and perspective of them and their members on those topics. So we wanted to acknowledge that that was out there. With the UVM Health Network, we did receive some feedback on the financial appendices and we took some of that into consideration and we'll talk about what we did there. And the healthcare advocate sent over some public comment which was two parts, part of it was public comment for the Board's consideration in guidance and the other one was their input for this year's guidance process. And we'll talk about that as we navigate. So we have a few changes as I discussed to the hospital budget guidance and appendices. So bear with me as I toggle back and forth. Some of that feedback was from Board members at the last meeting we had on March 10th. And some of the remainder was from some of the UVM Health Network proposed changes in their public comment, which we thought might add clarity to the documents that we've produced and presented here. So with that, I'll start with the hospital budget guidance and for those of you following at home, I am on slide four right now. So with the guidance, the one part that we added to here as we posted on our website was a little deeper line of questioning on page 10 of the guidance. And that came about from Board Member Pelham who wanted to understand a little bit more about certain aspects of the progress of value-based healthcare reform here in Vermont. So Elena Berry, the director of healthcare policy was kind enough to work with Tom to craft some of these questions which we've included in the guidance. So we hope the Board will consider the addition of those when approving the hospital budget guidance, but for those at home who can't be able to see my screen, I'll read each of those to you. And the question number one that's been added was, what is the tipping point or threshold defined as the percentage that true FPP or prizes of total NPR FPP necessary to support successful transformation of your delivery system to a system substantially based on value-based care? The second line of questioning was assuming Medicare and Vermont commercial payers offered true actuarially sound population-based fixed payment tomorrow. Over what time horizon would you estimate you could reach your local tipping point? How long would it take your hospital to move operationally to a mostly fixed budget through participation in all payer fixed payment programs? And finally, what would the Medicare and commercial fixed payment programs need to look like to facilitate your participation? So those are the items that we've added to the budget guidance document outlining the Board's expectations for the FY22 fiscal year. The FY22 fiscal year. And the other additions occurred in the appendices or the financial workbook. So UVM's feedback that we accepted dealt with a lot of house cleaning items on here that they felt would help clarify and offer a fuller perspective of the ask that we have here. So last week, these payer columns here on line 10 only contained Medicare, Medicaid and total commercial. So with their feedback, we added total self-pay and other and dish and down on the vertical axes we aligned this section here with what is being done down below in table three which is the projected to budget look. So we made some of those minor changes there. In the past, we've had these payer fields. More detail, we were trying to streamline that down. But if the case is that we're actually impacting the story being told by trying to be too streamlined then we'd rather have it be built out to where it provides a better perspective for the Board and it's a clear understanding for the hospitals of how to populate this document. And this is more in line with years past by bringing out dish and total self-pay other in addition to commercial Medicaid and Medicare. So we did accept the request to make those changes. We also on appendices number one, we linked the inflation increases from the inflation tab to this tab here for ease of use. This will now populate based on the response that comes in here in dollars. So again, we're looking for the price effect. Nothing on the inflation tab has changed. It's just gonna drag that price effect as we've noted here into this spreadsheet. So with that, we've also made some changes to appendix two and we clarified some of the language up here. We still had some language talking about gross charge, et cetera, we changed that to gross revenue based on this increase in considering utilization of assumptions and acuity, really what we weren't being as clear as we could be. So we accepted their input on that as well. So those are the changes that we made to this spreadsheet here. They offered some other input as well, but seeing as how we need to regulate 14 hospitals, some of those discussions really should involve more stakeholders than just UVM. And I don't believe it was their intent that we consider all of this feedback. It was simply the fact that they wanted the opportunity to provide feedback and we allowed that and we brought some of that in here without making too many substantive changes to the workbook we presented last week. So like I said, most of it was house cleaning to be taken care of. Finally, whoops, I navigated too soon. We made a change to the COVID page here. Board Member Youssefer had asked that we include a Paycheck Protection Program funds line explicitly. So we've done that. And we also added columns to each one of these fiscal years here for amounts received. So there will be, these are subtotals of what's been received, which we'll add back into this grand total here. But now we'll see in each year, how much you've received, how much you've recognized in revenues and how much you've recorded in a liability. And we didn't break any of these down into subtotals based on grants and advances or what you gotta pay back and what you don't because as we've heard over the last couple of weeks, that federal guidance around grants continues to change and folks may end up having to pay back. We don't know yet some of those funds. So we didn't wanna take that any farther on that line of thinking. We think we've captured most of what we need right here with the additions that Board Member Youssefer provided us last week. So those are the changes to the budget guidance document and dependencies from last week to update everybody at home. Next, we've updated some discussion points. Some of the big ones that we're gonna have here today are based on the Board's request that the staff bring some varying looks to a potential discussion on NPR-FPP growth ceiling. We've done that with a recommendation by staff. The Board also requested that we bring some change in charge perspective to the discussion today with a recommendation and we've done that. And then there's a potential that the Board could vote on the standing enforcement policy that legal presented last week. There's been no changes there. And then the discussion around exemption from public hearings. So we'll have a discussion on that today and potential vote should the Board feel comfortable with the direction we're headed. And we've come up with a recommendation for that but there'll be an in-depth discussion around how that might work. And finally, we have the healthcare advocate input. They had not yet sent anything over as of last week and we did not expect them to. But today we have their feedback from yesterday with their input and items for consideration for the Board. So I'm actually gonna jump to that and then we can move through the NPR charge enforcement and exemption discussion. But we wanna acknowledge the healthcare advocates items that they sent over to us yesterday. So at the top of their document there's two bullet points for public comment and board consideration. And number one says, please describe to the best of your knowledge any other potential COVID-19 relief funds that your hospital could receive. The factors involved in whether or not you'll receive these funds and the current status of the funding process. So they're asking us to add this as additional request to the narrative section of the budget guidance. So we ask you to consider that. And then in the second bullet point they're urging the Board to specify how hospitals should calculate each reported data element to help ensure the meanings of the hospital's responses are fully transparent and standardized amongst other language below. And the staff feel that we already do this. We offer a uniform reporting manual. We have an adaptive user guide and all of these organizations operate under generally accepted accounting principles which transfer to their audited financial statements. So we feel that we've done an adequate job at standardizing these and as finance folks we operate under generally accepted counting principles. So we do not urge the Board to adopt that piece. We think we do it already and generally accepted accounting principles do allow for standardized approach in reporting and the hospitals all understand how we gather metrics through our reporting. So we feel that we're doing a pretty solid job of that now. So in addition to that, healthcare advocate is asking that these items here reimbursement ratio relative to standardized Medicare reimbursement be added. I'm touching on broad topics here. Hospital financial assistance and bad debt during COVID-19 along with some support information for that request, Medicaid screening processes and some perspective for that request as well. And then finally, a discussion from the hospitals on any analysis or tracking your hospital conducts or is considering conducting regarding access to care, care efficacy or satisfaction among vulnerable populations included but not limited to a group below that line. So we request the Board to consider those items for this year's hospital budget guidance. And with that, I will move into the NPR and FPP growth ceiling discussion. And Mr. Chair, just to clarify, do you want me to hold after each one of these so the Board can discuss or would you like me to navigate my way through this entire presentation and then we can come back to these individuals? I would prefer to bring up one chunk at a time. So I was hoping that at this point we could hear from the healthcare advocate on why they're asking for this information and then take public comment and possibly have a vote and put this one section behind us. Cause I think if we try to focus on everything we're just going to go back and ask similar questions again. So if that's okay with you, that would be my preference. Absolutely. That makes sense to me. So I'm not sure if Mike's on the line or Eric or Kayleigh but could you just give us a brief review of why you think these are important? I have to tell you that my opinion is that the healthcare advocate has the right under statute to ask for whatever they want to ask for. And in my view, it would be much better to ask upfront than make the hospital scramble at the end. So I understand the need very much so to make this process as easy as possible given the difficult times that the hospitals are under but I do think that we owe the respect to the healthcare advocate to hear them out. And again, whatever we don't adopt into guidance I still believe they have the right at hearing to ask again. So with that, I'm not sure, Mike are you on the line or who is? I am on the line. Thank you, Kevin. Thank you, Mr. Chair, Mike Fisher here. And so I'm also going to ask my team to chime in as I get it wrong or incomplete. But in the first section, yes, our intent here in the first bullet was just to get the best knowledge possible not only of monies that they anticipate or feel, you know, we had a little fear that the term anticipated could lead someone to a hospital to say, well, we're not sure so we're not reporting it. So just to get as full a picture as possible. In the second bullet, we continue to look for as much as possible apples to apples comparisons. And it's true that hospitals and the board ask for generally acceptable accounting principles. But that doesn't, it's not uncommon that we hear various entities say we've reported based on, you know, according to acceptable accounting principles that still don't align with each other. And so we continue to ask for as much clarity as possible. And I fully respect and understand the perspective that your staff just said, there is a great deal of effort and a great deal of improvement that's gone towards this. We continue to find particular areas where we don't feel like we can compare hospitals. I'm gonna pause for a second and ask if a member of my team has something to add to that. And I just wanted to say on the data definition issue that I fully agree that, you know, gap or an audited statement does not ensure that it's apples to apples, that there's very problematic leeway in that. And I don't think it's the same. I do wanna note that we put this in a letter to the board and Susan has said we're gonna have a work group on that. And so we did, we do note that. And I think it's really about a, rather than improving this year, because it's a huge task that the process and the stakeholder engagement start and not during this moment of crisis, but as soon as possible thereafter. So it was really just to put this issue before the board again, rather than saying, this is something that should be incorporated this year. Kevin, do you want me to comment on the next sections? Yes, please, Mike. So for the questions, I think maybe it's one, two, four. You know, these are the questions that we came up with. I do wanna note, I don't know who's driving, but if you could go right to the very bottom, just our invitation to hospitals that, that if there's any concern about it, we wanna be sensitive to the crisis that's going on. We're attempting to be sensitive with the number of questions and the details of questions that we've asked during this time, but we wanna project just as loudly as can be that we're, while we are interested in getting the answers to these questions, we are also interested in working with hospitals and don't want to provide an unreasonable burden. And so we are happy to work with hospitals to figure out a way to get, to bridge those two interests. So from the hospital perspective, I'd like to take any public comment as much as possible on areas that you think could be too burdensome or hard to do given the current climate. And I don't know if, Jeff Thiemann, you're gonna speak on behalf of all the hospitals. I noticed there's a lot of hospital CEOs on the line and CFOs, but basically I'll take public comment from anybody in their feedback on what is being proposed from the healthcare advocate. Chair Mullen, this is Mike Del Treco. Hey, Mike. Trying to get my video going, sorry about that. So I appreciate the healthcare advocates' recognition of some of these challenges that we're facing. I certainly will continue to work with them offline. I've offered that and their team and staff has acknowledged a little bit of a hold on till after this process is done. I would just ask the general question as I ask all the time of what value are these things to the budget process themselves? And if it should be outside of the process that would, because where it does may or may not impact the budget process that'd be good to know. And I would rather work on these outside of the budget process while instead of inside the budget process. Thank you. Would that go for all of the questions that the healthcare advocate has asked, Mike? You know, I looked at all of these and the other day and when I received them, I just, you know, for example, ratio of inpatient reimbursement to Medicare reimbursement standard by MSD relative weights. Like, what are you gonna do with that? I guess, and so it would be yes, outside of the budget process to all of them. Mike Fisher, is that anything that your team would like to consider as far as working with Mike and representatives from the hospitals to do this outside of the process? Or would you prefer that it be inside the process? I think I'm happy to talk with Mike in the hospital association in any particular hospital about how to do it right. I just wanna recognize the dynamic. You know, we have a right to ask questions in the hospital budget process. You're offering to, you know, and asking us to do it outside the hospital budget process. I know that hospitals and the hospital association is doing what it needs to do to put out fires every day, real fires, and that sometimes good intentions are hard to follow through on as we manage the pressures on all of our jobs. So having said all of that, recognizing all those pressures, you know, we're happy to continue to have this conversation and figure out the best way to get answers to the questions. Okay, and realizing that you're really not giving up the ability to still ask these, the hospitals are just giving up the ability to do it in advance if you still proceed with it. I think both sides would work in good faith and recognize the situation that everybody is in. So I guess my recommendation at this point is if the two parties are agreeable that we not make it part of the guidance and allow the parties a chance to work through the discussion. Is there any board member that feels contrary that we should not follow that process? This is Robin. I think that makes sense to me. I would leave it up to them. Although I will note that question one, which around the standardized Medicare reimbursement is helpful to me in setting the change in charge. So out of the questions, that would be the one that would be helpful to me during the pop in the process. The other questions I are interesting and have interesting information around what's going on in COVID. So I don't wanna minimize the other questions. For me personally, one is the first one is actually helpful in the process. So I just wanted to make note. But if people wanna take that offline this year, I'm happy to be flexible. Other board members? Kevin, I would agree with Robin that I think one is helpful in the budget process. I think the other one is if there is a movement to move them offline, I would support that. Outside of the budget process I think so. Yeah, I think we should include one in the budget process as well. And the others can be outside. Would somebody like to make a motion and then we'll just continue with the discussion? Sure, that's as the official motion maker. I move that we include the healthcare advocate question number one in the hospital budget guidance and leave the remaining questions to the parties to work through a process. Is there a second? I'll second it.  Did you have something to say? No, I think Robin's perspective is a fair one. And we'd all like to have everything that we could have but the pressures that hospitals are under, I think that we have to work as hard as we can to keep it at a minimum this year. So I thought Robin's perspective was a fair one. Okay, other board members, any further discussion? I'm gonna open it up for public comment before the vote again, but board discussion first. Hearing none, I'll open it up for a public comment from anyone. Kevin, Mike Fisher again. Go ahead, Mike. Yeah, I guess I appreciate that recognition of question one. We were motivated to, we have been motivated to ask it for some time but we've also noted that some board members' interest in that question. And so that makes sense and I'll just emphasize again that we do have a right to ask questions and we are doing our very best to be responsive to the pressures on the hospitals. So we'll continue to find the best balance we can on that. Mike, I know you and your office have always understood the gravity of the situation and you were great last year and I assume that this year will be no different. And we appreciate all the members of the Green Mountain Care Board, the hard work that the healthcare advocates office is doing every day. So thank you for your understanding in this. Does anyone else have any other public comment? I see a hand up from, Mark Sanislaus. Hi, Kevin. The only thing I would say was, census information was just thrown out of us this morning and in this meeting, I would advocate for even under Mike Del Treco's approach for this one, I don't even know if we can provide the data that's in that right-hand side of the column, even if we wanted to. So I don't know how to respond under public comment for something that you don't think you can provide to begin with, but so I would advocate will the approach will that boss put out there at least for this year on these types of questions. Thank you, Mark. And I'm sure that even if this motion does pass that you can have those conversations in that work group with the healthcare advocate. And if you can't do it, you can't do it. But at this point, is there any other? Is that, I don't even think we could provide that second column for all of those payers. So I mean, I just wanted the board to know that. I mean, to put something in the guidance that knowingly hospitals can't provide you know, that's up to the board's call. But, you know, since this was just thrown at us and you know, it would be great to have more time to react to something than this. Other public comment? Other public comment. Robin, based on the comment you heard is there any amendment to your motion or are you staying with it as is? Well, so I certainly am sensitive to, we did get something. I don't go back and compare how this question is asked this year compared to last year. So, but this is information that was in the questions last year or similar, I should say information was in the questions last year. So I'm just wondering like certainly it doesn't necessarily make sense to include something that people can't answer. So I'm wondering if it would make sense either to put this in as a placeholder and then, I mean, it's kind of a pain to revise the guidance or I don't know, come back to this. I don't know if next week is enough time for people to come up with a question that makes sense to both of them. But, so I just wanna stress that guidance is strictly that it's the guidance and you know, I don't think that anybody should get too worried about specific language in the guidance because if there is a sea change that happens between now and the submission of the budget process, there would be amendments to it. And so I'm comfortable with whatever you wish to do, Robin. And on this one, the motion could even be that to include this question subject to the outcome of the work group. Okay, yeah, so then I think I would amend my motion to include a question similar to question one as worked through with the work group. So that was not very artful, but basically what I'm trying to say is we wanna get this type of information. The party should figure out the right way to state it. We'll put this in as a placeholder and then we can revise it when we have the right question. It would have to be done in time for obviously hospitals to submit. Yeah, is there the seconder in agreement with the amended motion? I am. Okay. Is there any further public comment? Hearing none. Those in favor of the motion signify by saying aye. Aye. Aye. Those opposed signify by saying nay. Okay, so Robin, I believe that there is no further motion required as far as the discussion on the document from the healthcare advocate unless you believe there is. I think in the first part which, so Patrick had pointed out a suggestion for revised language related to the federal funding which is earlier in the document. We haven't talked about. And what I was gonna suggest here is it would make sense to me to have, I think it could be in the narrative but really what we're asking for is in that worksheet for the other columns to be, I guess I'm asking Patrick, does this make sense in the narrative to you or does it make sense on the worksheet? And in terms of collecting the information that the sense it is an evolving situation. So that's question one. To me, I would not ask the hospitals to necessarily each and every hospital to describe the factors and the status because it seems to me that the funding process would be either in law or in executive administrative agency and like last year we had AHS to come in and talk about the factors in the process. It seems a little redundant to have each hospital basically would say what should be the same legal criteria and process. So personally, I would figure out another way to do that so that hospitals don't have to deal with that. If they've applied for something and they don't know if they're gonna get it, I think we'd wanna know that. I don't know if that makes sense to other people but I think we could narrow it a little bit is what I'm saying. I think it does make sense because obviously we're getting the briefings on any bulletins that are released from HRSA or others, including the state of Vermont so that we could follow that. But Patrick, what are your thoughts? So to answer Robin's questions, I think it makes sense in the narrative not necessarily in the appendix because they may be anticipating receipt of something or to the HCA's point potential COVID funding. They're not gonna book that on that breakout because they don't know. So they can't just throw numbers in there. It would be a better talking point for them. A la last year when we were waiting on AHS, they didn't know, but if they think they've met all the qualifications, it would be nice to know if there's additional revenue coming down. So I think the narrative is probably where that belongs. Yeah, I agree with Patrick as well. I think it's the narrative because I think it's probably any funding that's not able to be put on the chart because they haven't received it. And I don't think the question is that, onerous particularly with kind of the new funding that potentially is out there and the uncertainty of whether people, whether they can get it or not, but they may apply. So it may not have gone through that process yet when they do their budget. So I think it's just a question of is there anything else out there? And since this is so evolving, we don't know what we don't know. And we don't know what's gonna be out there July 1st. So I think it's a fair question. And I think it belongs in the narrative. Somebody wanna make that motion? So I would move that we include in addition to the narrative which would ask the hospitals to describe to the best of their knowledge other potential COVID-19 relief funds that the hospital could receive including amounts and I guess I would say including amounts and that we would collect information regarding factors and process prior to the budget process ourselves. Is there a second to the motion? Second. Okay. Again, I'd like to open it up for public discussion and then we'll have a board discussion and vote. So any member of the public who wishes to offer any input on this motion? And Jeff Thiemann, I see your hand up. Yeah, Mr. Chairman, I would just add that we heard just this morning on a federal update that HHS is still very much in the process of even examining what the factors will be and determining how the application process works, the criteria, the eligibility. So just know that VOS is happy to supply the board with that sort of systemic information as soon as we have it and we'll keep you posted to the best of our ability on that. It's just still very much in process. There's not even an HHS secretary in place. Thank you, Jeff. And you always do a great job of keeping us updated and we really appreciate that. Other public comment, seeing none, I'll open it up to board discussion on the motion assuming my audio is not broken. I'm going to open it up to a vote on the motion. All those in favor of the motion signify by saying aye. Those opposed signify by saying nay. Let the record show that the motion carries unanimously. Moving on, Patrick. Thank you, Mr. Chair. So next up, we're going to move into some of the varying looks that some board members had requested we provide around NPR and FPP and some of the staff perspective on that and the staff recommendation. And Robin, I'm looking at you. We will have established motion language after each one of these next talking points. So we should be able to facilitate that a little better than our last discussion here. So I'll start off with, I believe it was board member Holmes had discussed last week about providing a potential hypothetical view of if we rolled forward 3.5% growth each year from the last year of pre-pandemic actuals being 2019 to take a look at where the system would have landed in each of those years and where fiscal year 22 would land. So up on your screen on slide six, you'll see us applying a flat 3.5% NPR growth rate to each hospital and culminating in a system perspective that ends up with a total system NPR FPP of almost $2.87 billion based on the roll forward from those 2019 actuals. In the next view, we took what you approved in fiscal year 2021 and we compared it to that hypothetical roll forward. So you'll see at the bottom which is the most important view here for the system is that there's about a 2.9% difference between what you approve and what that hypothetical 3.5 would look like if it had rolled over across those years up to fiscal year 2022. We don't recommend you look at individual hospitals because as we know, and I'll highlight Rutland here, their budget last year came in well under what it was for 2020. So in order to cover that hypothetical gap, it's going to show a much larger year over year growth differential there at 14.9%. So it's not exactly an individual hospital look. We kept with that consistency, but really that 2.9% is the focus for this slide in comparing that hypothetical to what you approved for fiscal year 2021. On the next slide, we wanted to provide you with another perspective that takes what you approved across the system. And if you were to approve a 3.5% growth on top of 2021, where the system would end up and where each individual hospital would end up. Now this is a little more important to look at each individual hospital because now we're saying if you approve 3.5%, here's the growth potential for each hospital. And the system would come in at 2.88 billion. Now that's a little higher than the previous slide by about I think 17 or 18 million dollars. So 3.5% growth on top of what you approved would come in slightly higher than the hypothetical situation that we've laid out for you to this point. So I hope everyone is following along. These are different perspectives to help our board understand the potential for a hospital system based on varying looks. And a lot of times we would just do this in a large spreadsheet and we've had to break it out in these individual slides. So I hope you can bear with me as we navigate. So pivoting away from that look, the staff, as many of you know through the reports we've done over the years and up to at least two weeks ago, whenever we look at the system, we try to provide a five year look back for context based on what was approved by the board and what actually happened. So here we have 2015 to 2020, that's six years but it allows us to do two slightly different five year looks. So on slide nine, you'll see the budgeted growth ceiling set by the board in 2015 to 2020. And it ranges from a low of 3.2% in 2019 to a high of 3.8% in 2050. To the right of that, we have the actual growth that occurred in those years. And that ranges from a low of negative 6.3% that we've discussed in the last couple of weeks or 2020 all the way up to 5% growth in 2015. So the two different looks we're going for here are, one, we're looking at averages versus medians and two, we're looking at fiscal year 16 to 25 year look for an average. And then we're omitting 2020 because of the actual activity that happened despite the board approving for the point five. So we're looking at a world with a five year look with COVID and a five year look without it for averages and medians. And we're trying to dial in some relative judgment here based on what the system has actually performed and what its potential could be moving into fiscal year 22. So you can see here at the bottom the two five year looks, including excluding the averages for the budgeted growth ceiling really don't move because again, the window is much smaller, 3.2 to 3.8. But when you look at the actual growth there's a much bigger variance there within without COVID it's almost 2.3%. So the averages are dragging down 2020 especially is dragging down the average for the view that provides the average and that 5% pre COVID is pulling that average up. So there's a pretty big window there fluctuation and variability between those two looks. So we wanted to take another look that might remove those outliers. And in order to do that we decided to look at the median. So you can see here the median with and without for actual growth is only about 0.1% difference. And in fact the one prior to aligns with the hypothetical that we set out earlier in this discussion. So we've got a hypothetical that percent variance from what was actually approved. And now we've got a median with and without COVID that is relative to that range. So we decided we'd go with the median perspective because those averages can be greatly skewed by the activity that's covered especially impact. So with that, the staff is recommending 3% NPR budget to budget growth. And our rationale behind that is it does allow the hospital system for room to grow for utilization bounce back. And of course we can fully admit all of us the hospitals included really don't know what that could look like as society becomes vaccinated. We are as a hospital system and provider care network very dependent on human behavior for what happens in the coming year. And so we think the 3.5% budget to budget growth might be a little too high considering all of that unknown regarding utilization and budgeting challenges during the pandemic. And because we're looking at medians at 2.8 and 2.9% and if I toggle back up, we're looking at a system between 17, 18 and 19 that shifted between 2.8 and 2.9%. So we feel three is a number that allows for some utilization bounce back but likely does not acknowledge so much utilization bounce back if the system gets back to 3.5% MPR growth. So with that, our perspective also maintains that historical information. And again, we use that median actual to actual growth to remove the outliers from COVID. So Mr. Chair, I'll stop here at the motion language because that concludes our piece on MPR and we'll turn it back over to the board to discuss the varying looks the staff have provided on MPR FPP growth and the staff's recommendation. Okay, four questions for the discussion. NPR FPP recommended ceilings. I have a clarifying question, which is, so we're in the guidance document, we had included language that would indicate that COVID vaccine related expenses would not, you know, could exceed NPR. So when we're thinking about this piece of it, we also have, there is really an additional variance to go above this related to the, I don't have the exact language in front of me but I just thought we should have this in context of that piece as well. But you're correct in your understanding at least as far as I understand it, that we have made it clear that the anything, any expense related to testing and vaccines should not be treated as traditional operating revenue or expenses. Have I got that correct, Patrick? That's correct. We're providing a breakout for that. So you'll be able to see what the hospital is requesting with that information built in and what they're requesting with that information extracted. Other board members. Yeah, just a couple of questions. And I think we may not know this answer, but do we know where things are trending in 21? So, you know, how far behind they are? Do we even have first quarter data there? Cause it would be good to get a reference point on how 21 is looking. You know, I also think either for the record or whether or not we're going to align on something today or not, but we may want to have a chart that actually shows what you're doing, shows the 3% compared to the three and a half compared to the three year trends that we had looked at. So kind of taking all everything we have for potential 22, right? One was doing the, you know, I think one is at 2887. So we have the three charts, kind of one is at 2869. Then if we did the three and a half year, three and a half percent growth, that's 2887. And I think this is 2872, 2.872, is that correct? The 3%, so that's the number we're comparing if other board members wanted to look at what is 3% equal, right? So you'd like us to provide this look up here on the screen with our recommendation? Yeah, I think, you know, so this is three and a half, right? Which is 2887 at the bottom. 3% is 2872, which is close to the three and a half percent growth trended forward on the first slide, which was 2869. So I'm just trying to put that relative in all those. But then I would add to that. I'm not opposed to sticking with the three and a half with the thought that, you know, maybe 22 is going to be the year without COVID at all. And 21 is certainly still impacted by that. And, you know, I know from people I've talked to, they haven't gone to the hospital doctors and things for things maybe they would normally or would have in the past couple of years. So kind of what we thought maybe was going to happen this year, which is the pent up demand would move forward. I think that may still be kicked out a year, but that may be something when we get to public comments, some of the hospitals could respond to whether they think that's the expectation or not. So it's really, to me, it's more there's just still this unknown of what will happen and whether to put it at three or three and a half. And also depending on where we go with the future conversation on charge, you know, there'll be limiters on, you know, how people could get there. It's going to happen or not, right? Either people are going to come in the door or not. So I'm not opposed to doing three and a half but would like to hear what other board members think. And again, it's really predominantly because of the unknown and whether or not this pent up demand will come back at all. And if it's going to occur in this fiscal year, which we're already six months into and still in the pandemic or going into next year. Kevin, maybe I'll hop in there if you want another opinion. Go ahead, Jess. Okay. So I've done a lot of thinking about this and the uncertainty absolutely weighs on me that Maureen was just talking about. I think we can all appreciate the struggles that we've had over the past year and indeed that we're still in a current pandemic. I just hope on the horizon, but we don't really know, right? Variants are lurking, not everybody's vaccinated yet. And we don't to Maureen's point know what pent up demand is going to look like. So there's a lot we don't know. I think I want to just circle back to what we do know is that pre-COVID hospital margin averages were under 1%. Seven hospitals were in the red on their operating margin. Hospitals are now emerging or, you know, hopefully we're in the later stages of this pandemic in very, very financially different positions. If you look at fiscal year 20 actuals for North country, for example, they posted their highest operating margin in at least the last five years. It was a healthy margin of 3.7%. Quarter emerged with their second highest margin in at least five years. The academic medical center, at least as far as I remember, posted their first operating loss for the first time since I've been on the board. So very, very different positions that they're emerging from the situation from 2020 and the total margins telling even more complicated story, right? You can look at Brattleboro's year over year increase in total margin, you know, 600 plus percent. UVMs was 127% decline, right? Some of those dollars that are contributing to those margins may be clawed back by the feds. We just don't know. So regardless, I feel like we're in a lot of uncertainty and the situations for each hospital are so very, very different. So my point is every hospital is unique. They always are, but this year more than ever. So I'm gonna take an interesting, I don't know interesting stance that may or may not have be a consensus place where we can build consensus around, but I feel more and more strongly as I think about this that applying a one size fits all hard and fast ceiling and the budget guidance even recognizing that it's budget guidance and we would always review the budgets anyway. But I feel like that is not an approach that I would want to personally take. I don't feel like I have enough data to feel comfortable setting a target or a ceiling. Frankly, I would rather see the board adopt a process that allows every hospital to submit a budget that allows them to maintain and improve access and quality, cover their costs and move towards more sound financial footing if they're financially vulnerable right now. I would hope that the hospitals would consider affordability in that approach as they're thinking about what their commercial rate changes would be and recognize that commercial rate is not the only vehicle through which to increase financial sustainability. But along those lines, while I don't favor setting a hard and fast ceiling on an NPR or frankly, even charge, I would be in favor of a process that allowed presumptive approval. I brought this up last Wednesday of any submitted budget whose NPR FPP growth rate falls at or below three five and has a change in charge. I know we haven't talked about that yet, but since we're talking about NPR to me, they go together. That change in charge would be at or below three five. And let me tell you why I sort of honed in on these numbers. Why three five for NPR? Like Patrick just went through, it's the median budgeted growth for the past five years, right? The average for 2015 to 2019 was three six. The median actual has been lower at two nine, but I also think that this three five allows for I think the very real possibility of pent up demand, anecdotal evidence of course, but I know many people who are seeking care but waiting for the vaccine. So, and we know we've been hearing from, there's other sources out there that insurance companies and others who are projecting return to a lot of this demand that we're not seeing in 20 and maybe not even seeing in the first half of 2021 because people are waiting for their vaccines to go out and get the care that they've postponed. I can talk about the three five. I can hold off on that piece, but I guess what I'm arguing in favor of at this point in time is we have too much uncertainty to set a target. And I would rather allow some flexibility for the hospitals to submit what they need. We will then scrutinize, they'll have to justify their need for whether it's NPR or whether it's their charge or whatever the components that we would be looking at. But if a hospital falls below, at least those two parameters for me, I would feel comfortable saying you've met these thresholds and we would waive your hearing assuming some other conditions are met and some of your future slides, Patrick, go through what some of those conditions might be. But I think I'm just, I'm arguing in favor of not having hard and fast ceiling but allowing presumptive approval of budgets that fall below a certain threshold. So just one thing I just want to correct there, there's nobody that has any language that suggested a target. A ceiling. Okay. I guess I'm not comfortable setting a ceiling when I don't know what pent up demand is going to look like. I don't have that crystal ball and it feels uncomfortable to me without having evidence to set a ceiling on NPR growth, recognizing full well that this is a guidance but I would prefer not to do that. So that's my personal position on that. Thank you, Jess. Other board members? Yeah, the word that Jess uses uncomfortable, I feel uncomfortable with a ceiling too. And I kind of look at the 2021 budget where the distribution of that 3.5% we ended up with the NPR increase of 2.7% but UVM Medical Center got a 5% increase and the rest of the hospitals combined were at 4 tenths of 1%. And so here you have these 4 tenths of 1% hospitals kind of coming into 2022 and I don't have a feel or information as to how things are actually going on the ground during this year. So I'm uncomfortable having a ceiling that applies to all hospitals or that apply system wide and therefore applies to all hospitals without having some flexibility in the distribution of that across hospitals because a hospital coming in with a 4 tenths of 1% increase for 2021 over 2020 is different than a hospital coming in with a 5% increase, I would think. It was a very skewed distribution in 2021 and that worries me that we head into 2022 and there's not flexibility, if there is to be a ceiling there's got to be some flexibility to move that around so that all hospitals are treated fairly given their history. And I don't know what that is yet but I aligned myself with Jess in terms of feeling uncomfortable about a kind of a blanket ceiling that's applied system wide when we have these 14 hospitals in a skewed system in 2021 or a skewed distribution in 2021. Other board members? Yeah, I'll just add a couple of things. I mean, we've, this has always been a challenge, right? Having one fixed number for all the hospitals. I think I've brought that up multiple times over the years that everybody is not the same. So I think that that is part of a challenge there that we face when we look at each hospital and what their demographics and what's going on. One other way to look at whether it's a ceiling or kind of a variable number could be to propose something where we, whether it's 3% or 3.5% and then for hospitals to show what their added utilization may be, you know, pent up demand might be that might bring them above that. So I guess the issue is really what would be above that number, right? If we did boo a ceiling and then we got hospitals that came above that. I'm just throwing that out there as an option.  And so as you roll forward into the next year, you know, where do you start, right? Is part of it well, whatever was in 22 had a component that was pent up demand. I mean, I think if we do this, it's going to carry into the next year as well to a degree. It may not be so much a ceiling as to say, is it going to be below? But, you know, in the event that pent up demand occurred in 22 that maybe inflated that number and wasn't something that would carry over. And I know that the hospitals obviously have discipline as they're going through this. A concern is they work on such in margins and expenses tend to happen as we saw last year with the numbers, lots of different moving pieces, absolutely, but NPR didn't, expenses did. And as if there is no ceiling and no guidance there and the numbers are built higher, their expense budgets will follow and be harder to cut. Not saying we manage expense budgets. That's not what I'm saying, because you know, there's been some pushback on that.  So whatever you put for top line, you're going to have an expense load there and what has been shown is an inability to bring those expenses down when you don't hit the top line. So I do agree though, that there's a lot of uncertainty. So I'm not saying I wouldn't go for that. I'm just trying to put out, you know, let's also make sure we're thinking about the year after and thinking about some other things in there as well. But I've always said the 14 hospitals are not the same. And, you know, three and a half or some will never hit it and others might exceed it if they have more patients coming and things like that that would drive that. So, you know, maybe it's the time to start to get away from that. I don't know. Other board members. Sure. I like the idea of setting. I can't remember exactly how Jess described it, but setting basically a threshold for presumptive approval that it would include an NPR number and a charge number that would allow for waivers of hearings. And we can talk about the criteria for that in the later slides. I like that idea to me the whole, like I'm not uncomfortable with the ceiling because quite frankly, I've always thought of it as a ceiling and that's from the long ago statutory development and legislative discussion. It was meant to act as a cap. So, and with the idea that the guidance was guidance, it was not, it was going to be tailored to each of the 14 hospitals. And we do do that every year. So it's not meant to be hardened fast in that sense. So I guess just because this is the way I've always thought about it is that it's meant to provide kind of a directional signal about submissions, but that of course we get tailored based on individual circumstances. With all that said, I think it may be just kind of semantics because I think that in reality, if we do end up going with this concept of a threshold that would waive hearings, then that's how the guidance would read. And so it kind of takes away whether we need to use the word ceiling or not in that because it's a different sort of setting really that the hearing waiver becomes that piece of the written guidance. So that's just my two cents there. In terms of the number, I, and I'll just stick with NPR to start, I, in looking at the historical performance and the analysis that Patrick and the staff did, which I found very helpful in thinking about all the uncertainty in the pent up demand, I would be more comfortable going with three and a half percent. And that's in part because of the historical looks that are in the staff materials. And while I think people sometimes think that the three and a half was kind of an arbitrary number in the all pair model, it was actually linked to historic economic growth. And so it's not just a number picked out of the sky. And to me, the point of doing a total cost of care framework in a statewide agreement is to set really a goalpost, if you will, over a long period of time. So it's the consistency with that and the previous economic growth is also appealing to me, although I certainly would understand that from a CFO perspective, state economic growth historically may or may not feel like the right conceptual approach, especially in COVID era. So coincidentally, it also happens in this case to line up around the average and a little bit higher than the median to allow for that bounce back. So that's just my initial thinking. I'm open to, I'm not stuck necessarily on that specific number. I'm open to other conversation and public comment to before I finalize that particular thought. Thank you, Robin. So I'm gonna offer my two cents. It's probably a minority opinion, but I agree with most everything that's been said by each of the board members so far. So I'll proceed with my minority view. And like Robin, I have always considered that the board look at each and every hospital on an individual basis and that process occurs at hearing. And this is guidance moving into those hearings. And so I think that because costs to Vermonters are not just a function of the actual prices based on utilization as well, this isn't unprecedented year. And it will be tough for anyone to have the crystal ball to look into and come to that. But with that being said, I still believe that there should be language in the guidance. If I had to pick the magic number, it would be 3.25%. And if we were to go down the road of a presumptive approval, which I do support, I think that number has to be lower than what is in the guidance. And I think that number should be at the 3%. That's my two cents. Any further feedback from the board before I open it up to public discussion? Yeah, just to go on what you were saying, Kevin, as well, going back to the decisions that we had last year. And we had obviously a ceiling for last year. And we had several hospitals. I'm trying to count them up, but maybe nine of the hospitals came in with higher requests than the ceiling. And I think five of them, we agreed to higher amounts versus the ceiling. And the couple that we brought down had a history of asking for much higher and never hitting the number. So we wanted to try to bring them down. We said, if you get there, fine, but you haven't done that in the past. And so we don't want to tie in those expenses. But the point of that is really to show that, yes, we put this number out there and we have, in some cases, significantly gone above. We had an 8.7, we reduced them to 8.3. We had a 5.7, we did reduce it to five. We had, most of them, we had a 4.6. We gave them the 4.6. We had a 5.3, I think we brought it down to 4.8. So we had many that we allowed over. So I think it's kind of, do you say, okay, there's no ceiling, right? And then that gives one message, or I think my vote would be more to put the ceiling in, put it in at three and a half. I know that as each hospital comes in individually, we are gonna look at that. And that's what we have done in the past. And many last year came in below the numbers. And so in total, I think it came out lower, but there was certainly a mix of more than half of what we asked for, higher numbers. And we gave higher numbers based on that. So I'm not caught up on if we put a number, you know, we don't, if we have a number out there that we won't listen to what each hospital comes in with. If I could just, you know, I mean, your point is very well taken, but it sort of suggests that setting the signal and setting the ceiling is rather ineffective, right? If half the hospital's exceeded in their budget submission, it's a rather an ineffective tool. In a year where we had more evidence about what that ceiling should be, I would say, hey, this is the ceiling and here's why and we're using, you know, evidence to back that up. But in this year where it's really very unclear what that ceiling should be and, you know, it's last year proved to be ineffective at setting that ceiling anyway. I guess I would say that if we're interested in sending signals about what we feel like are some guardrails, we do that through the waiver thresholds. That's setting the signals and some signaling what we think is appropriate or hopeful budgeting, but it allows for the flexibility. And I would also say sometimes in my experience when we've set ceilings, some hospitals will try and hit that ceiling, even though it's aspirational and they can't make it.  So you've got issues on both sides. And so this year to me, and I'll stop talking after this, but with so much uncertainty and with it's proven ineffectiveness last year anyway at, you know, being particularly meaningful because hospitals are gonna submit the budgets that they need. Why not let hospitals submit the budgets that they need? And then we do what we always do, which is look through all the hospitals and try and understand what are their needs. But by sending that signal about what the waiver thresholds are, we are supplying some guardrails and we're relinquishing some of the administrative burden associated with the hearings and all of that if you've met those thresholds. So that's, I guess, my final say. Other board members? I just strongly disagree that it's ineffective. So I mean, because I think the point is to speak, because quite frankly, like we acknowledge that the only way to make a more nuanced than ceiling would be to do it with more nuance and have it by hospital category. I mean, we're looking at it as a statewide kind of high level tool. So of course there's gonna be a lot of variation. So I don't actually agree that that's a signal that it's an effective. I think there's just a lot of variation in our hospital system and that's appropriate. But it does give the hospital some idea of where our heads are and overall growth trend. So that's all and now I will be quiet. Other board members? So at this point, I'm gonna open it up for public comment on a discussion on NPR, FPP. And the first hand that I saw up was Dale Hackett. Dale? Can you hear me? We can. Okay, I just have a concern as the best I can follow it. Either 3.0 or 3.5. I think what I would wanna focus on is the issue of that backlog. And I don't know it'll show up in 2021. I see it as first they have to get to a point where there's enough people vaccinated that you don't have 15 minutes between each patient seen. That will increase utilization, but that's normal utilization they're trying to get back to. That could easily take 2021 to do that. And then it's in 2022, that ceiling you're talking about, if you think of it as more of a roof with two feet of snow on it, or instead of two feet of snow, it's two feet of names of backlog of people that didn't get their annual checkups. You don't even have the workforce to serve the backlog unless you hire people because you gotta increase the utilization capacity to work off the backlog or you never actually do work off the backlog. You will always stay behind. So do I want to put a ceiling that prevents them from doing what they need to do to catch up? No, I'm pretty sure I don't. I can probably capture the data. What's a patient seen and what's a patient that is backlog because it's gonna be right in the records. They should have had their annual checkup last April. They didn't even get one this April. It might be they get a checkup next January. I can capture that data and show it as it's backlog. I don't know how much that costs the hospitals. I don't know how difficult that is within the analytics. It's pretty easy to say. As we've seen so often, easy to say and easy to do, that's not an apples to apples comparison either. Excuse me. So I don't know what the right number is. I know I don't wanna keep them from doing what they need to do to actually provide the services needed. I'm afraid I have to stop there as far as my comment. It doesn't really provide an answer. It just provides I'm concerned about preventing them from being able to do that and to comment. Thank you, Dale. And I think that everyone shares that same opinion that we want people who have delayed care to get the proper preventive care, the proper screenings, the proper checkups to make sure that they're not more expensive going into the future. But I still think there is a proper place for guidance here. And with that I'm gonna go next to the next hand I saw was Jeff Thiemann and on deck will be Claudio Ford. So Jeff. Great. Thank you, Mr. Chairman. So I had a few comments that were sort of on both substance and process. So I'm just gonna make them all at once if that's okay. That's fine. Okay. So I just wanna start by rewinding for a minute back to a 2017 Green Mountain Care Board meeting that no one probably remembers, but where I said that we need to have budgets that are adequate so that hospitals can manage any kind of emergency response. Four years ago, without any kind of glimmer of COVID in my eye, I knew that statement was true. It's our social duty to be prepared for this kind of crisis. At the time I was thinking more like a tropical storm or a mass shooting, we now know one year into the global pandemic that has killed millions that COVID's a lot worse than anything we could have imagined. So my comments may have seemed at the time like a dramatic expression of a worst case scenario, but look where we are. So I do understand that when the regulator heard our request from the association to suspend the annual budget review process that it may have been shocking. But having worked so closely with our hospitals over these last 12 months on pandemic response with life and death repercussions every day, I will go to the map for them over and over and over again. If you sat where I do, you would do the same and you would wanna clear their decks, give them room to breathe and plan, and you would advocate on their behalf without any reservation. We need to prioritize public health and pandemic recovery, which is really what prompted the request for relief from the process in the first place. And in a related note, hospitals need the ability to grow and operate at a level that enables them to continue their missions, to avoid considering cutting services or making programmatic changes that could threaten access. So we strongly encourage you to regulate hospitals and choose a mechanism for that that enables both margin and mission. If you're unwilling to suspend the process as today's discussion would suggest, we encourage you, as we did in the letters, to streamline it and enable hospitals to achieve a reasonable margin and grow at a rate that at least matches medical inflation. This is a very unusual moment, and all of us want to emerge from the pandemic stronger, not weaker, more resilient and ready, not less so, declining margins foretell a pretty daunting future where access could be limited, quality eroded, and costs growing. So on the simplicity piece, just to be clear, what we mean by a process that's simplified is minimizing follow-up to hospitals and the Q&A process, creating an option to avoid hearings, as has been discussed a little bit here today, of hospitals coming at a certain level. Those are steps that would simplify the process and deliver some of the information, or most of the information, that you need to do your job. So I'm somewhat encouraged by the direction of this conversation, although the details still matter a lot. Put simply, we think you should allow for NPR growth that provides for hospital stability and covers inflation at 4% to 5%, which includes pharmaceutical inflation and increased COVID expenses among other areas, that you use your regulatory authority to regulate through the collection and assessment of information throughout the year, and of course allow hospitals to invest in their facilities and in health reform and in social determinants with a constant lens on affordability and all the priorities we share. I know this is super hard work. I'll just repeat what I always say, we share the same goals, but how we get there is really important. This is not an ordinary moment, so I would hope we don't treat it as one. And since I've read from my pre-written comments, I am happy to submit them for the record. Thank you for listening. Thank you, Jeff, we would appreciate if you did submit those for the record, and thank you for your thoughtful response. So next is Claudio Fort, and after that, next in queue will be Hamilton Davis. Claudio. So hi, folks, I'm Claudio Fort. For the past three years, I've had the privilege of serving as the president and CEO here at Rutland Regional Medical Center, and prior to that I spent about 10 years as the president and CEO of North Country Hospital. So I've had the opportunity to see the perspective from the Northeast Kingdom to Rutland County from a critical access hospital to a PPS hospital. And I'll echo some of the things that Jeff Thiemann said on kind of the environment here in our hospitals right now. It has been an unprecedented year for us. And I think we have responded admirably. I think our whole state has, and I extend that to members of the board. I appreciate some of the consideration that you have given us over this past year and that you're hearing our appeals and our pleas. And I know you're in communities where you see the work that we are doing on the ground. But the staff here have done just some heroic work. And we've stepped up testing programs and now within a couple of weeks we developed a vaccine program which is very, very complex and complicated and no one's ever done it before. And so a lot of our staff are stretched pretty thin. They have, their world has compressed. And I think for healthcare people, I think we have to appreciate that the leaders in healthcare, the clinicians, not only have their own burdens to carry and their own challenges, but they take on those of the patients and the vulnerable that they serve. And the leaders here in the healthcare organization take on those of the fears and the vulnerabilities of the staff who we are leading and trying to do this. So your consideration on this year's budget process, which is so atypical would be appreciated. And just a little more specifically to echo some of the comments and I appreciate those from some of the board members for Rutland Regional to set a 3% or even a 3.5% budget to budget NPR FPP growth ceiling essentially bakes in what we believe could be temporary and artificially low volumes that we projected in our fiscal 2021 budget. And these lower volumes and revenues were directly due to the COVID crisis response. And the challenge is we do not know if those volume reductions will be temporary or are they gonna be permanent or are they gonna be somewhere in between? As Dr. Holmes said, we may see a phenomenon of pent up demand and experience atypical greater volumes throughout fiscal 2022. As more confidence patients, confident patients catch up on care they've put off. Conversely, we may see a slower return to pre COVID volumes or we may never see those volumes return. The fact of the matter is no one in this meeting has ever experienced anything like this unprecedented global health crisis, not in our lifetimes. And we simply cannot predict what the longer term effects or what the new normal will look like. So I appreciate your consideration of our situation and your consideration to not impose restrictions like these artificial ceiling amounts this year that could significantly hamper our hospitals and then by extension our community's ability to recover during this critical year. So thank you for the ability to comment on that. Thank you, Claudio. And of course we would look at what you had put in for last year's budget during the hearing and understand that you along with several of your colleagues put in budgets that took into account the fact that you quickly realized that there would be a decrease in utilization due to screenings and protocols and all kinds of other factors that were involved. So the next person up will be Hamilton Davis and Tom Dee will be on deck. Kevin, can you hear me? We can, go ahead, Ham. Thank you. I think it's very interesting. I think it was really, I think the whole board discussion starting with Jessica's little talk is getting at the point. My view is this and I think in this room, an actual room, I've been in more of these hearings than anybody else years ago. I think that it really doesn't matter what you said is an NPR ceiling. What really is going on in the system is that any hospital, I don't care whether it's Grace Codge or whether it's Rutland with quality of four, they're gonna take care of the patients that come in their door and they're not gonna turn patients away, they're gonna do patients that they get. And what we've had for several years that Maureen keeps pointing out is they're aspirational to get small hospitals, critical access hospitals that hope to have more traffic and they end up with less and so their expenses go up but in fact, they can't get the patients. If any hospital is gonna do all the patients that it can get in the door. And the question then is how you manage that? To me, the two problems here are really that you can't regulate, I don't believe, you can't regulate a 500 bed academic medical center that basically pays all its people out salaries with 25 bed critical access hospitals. But I think, so I don't think it matters where you come down on this, you can do, you can have a ceiling for a, call it a ceiling, call it anything you want. You can have an NPR number, okay? And just call it an ice cream call. You can have that number for all the hospitals. It won't matter that all the hospitals will do all the work that they can do. The price that I think, I know we haven't gotten there, got there yet, Kevin, but the real issue it seems to me is that the really driving question here and so far as regulation is concerned is gonna come in the next piece, which is given what the people have, people, given that the hospitals are gonna do what the hospitals do, Claudio Ford's gonna take care of all of his patients. Whoever's running, Gifford is gonna take care of all of his patients. Rush, that's gonna take care of all of his patients. The real question will become how much, the real hard question is, how much will you let the hospitals recover in your commercial ask? Thank you. Thank you, Ham. Tom Dee, and next on deck will be Steven Majetic. So we're gonna get the Bennington flavor. Yeah. Thank you, Kevin and the chair, I'm gonna make sure. Can you hear me okay? We can, Tom, go ahead. Okay, thank you. And I wanna just state and I appreciate the direction of the discussion that Jessica was starting to drive this. I think it's, I think this has been a very thoughtful process by discussion by all the board members. So I applaud you there. I really have to support the notions that both Jeff and Claudio raised. I think, you know, at Southwestern, we take this, the Green Mountain Care budget process very much to heart. It really is. I will tell you, we kind of take it as an organizational challenge and we have institutional pride of how we develop the budget process. And it really is very much of an organizational wide effort. It's a top-down bottom-up effort that we spend countless hours doing this. And if there's ever a time for all of us to take a step back and to understand that this is a special time and we need to think outside the box and you need, and I know this may sound crazy talking to the regulatory body, but you need to have a little bit of trust in us as to what we're trying to deliver here and what we're trying to do and that we will be doing the right thing. And, you know, as I look at our organization over the last year, you know, we have pretty much done many, many different things that are out of the norm. You know, we've now have been an incident command every day in terms of really the past year getting ready to deal with this challenge that we're faced with. And we've needed it. You know, it wasn't long ago, a few weeks ago, we were running at 25 COVID patients a day here and we have redeployed our many, many of our management team members and our employees to help deal with this. And they've done it in a selfish way. And it's really has been taxing. Our team is really at a point of, I don't wanna say a breaking point, or a point that we're tired and we don't have a lot of juice left here, but yet we see some light at the end of the tunnel which makes us feel pretty good. But we have things here that we, a year ago, we didn't have. I mean, I have over 50 FTEs, redeployed FTEs who are now staffing vaccine clinics and we have now three testing centers. We've created a respiratory evaluation center for our COVID patients. So what we're going through is something that I have never dealt with in my career and it's very hard to predict what's going on. One thing I'm feeling more and more confident, we're gonna see it bounce back in the next 12 months.  And I don't think people are just, the health of our populations change. People are staying away out of concern and fear, but they will bounce back. And I think the more you can provide us the flexibility to do what we need to do with appropriate safeguards and guardrails in place. And I think we know we need to do that. I'm urging you to trust us to do the right things and to continue to monitor us. And we will stay close in contact with you, each hospital will. And I feel confident that we could respond to any requests that you have. But in terms of developing a major full-blown budget process, you just don't have the horsepower or the energy right now. So I view our relationship with the Green Mountain Care Board, even a URL regulator, I think we've been partners in care. And I'm willing to, I'm certainly, I know the other hospitals feel the same, we'll continue that partnership. But this is a time for us to do things differently and don't box us in a way that it's gonna hurt the hospitals and it's gonna hurt the community and the patients we're serving. So again, I thank for what you guys are doing. It's a tough job. This is not an easy one, but we're gonna get through this together. But I think we all need to cooperate and have some degree of trust and faith. And I know we need to verify and we'll do that too. So thank you, Kevin, for what you're doing. Thank you, Tom. Steve. So I was raising my hand to try to, because Tom was having a technical problem on his computer. So I'd just like to add what he said. Those 50 FTEs- It's always good if you concur with your boss, Steve. Yeah, I know, right? But I'll just add to the 50 FTEs. These are not new FTEs. As Tom said, these are redeployed people. These are people in our billing office working at the vaccine clinic. Well, they're not given vaccine there. They're registering people in the testing clinics. So we've redeployed a lot of people. We do have some clinical people that have gone from the offices and the physician practices and now are in the vaccine clinic or working in our respiratory evaluation center or in the testing center. So there is, you know, the organization is trying to respond. And, you know, any relief we can get in some administrative burden, we've internally here knocked out a lot of administrative things because the most important thing today is taking care of our patients that are sick, testing people in the community and getting vaccines in people's arms. And that those are as well as, you know, anybody else coming in, getting the high quality care that we provide. But that's our focus. And anything we can do to alleviate some administrative burden would be greatly appreciated. Thank you, Kevin. Thank you, Steve. Next in the queue is Steve Gordon and on deck will be Dean French. Steve. Yes, hey, Kevin in the board really appreciate the opportunity to talk. I just want to make a couple of comments and completely agree with Claudio's points as well as Jeff and Tom Dee. But, you know, I want to go through a little deja vu with you all from what Patrick presented and the staff presented a couple of meetings ago about how we ended the fiscal year, this last fiscal year, the actuals. And throughout almost every hospital you saw major services significantly below prior year and certainly below what we had budgeted to the tune of anywhere between 10 and 20%. I want to give you a little sense of where we are in Brattleboro, you know, boots on the ground here is we have not seen any kind of bounce back. And unfortunately, we encourage, you've seen the first quarter numbers, a two million dollar loss. And the bigger question from my board is Steve, what are we going to see for the rest of this year? Well, we are starting to see some level of improvement. But I got to tell you, we still have a real question of how fast and how effective dealing with whatever we're calling this pent up demand or a backlog, I haven't seen any of that to be very honest with you. Our ER is still down by 20% volume. Inpatient is down by 20%. We have a 5% drop in our medical office visits, 40 to 45% drop in births here at the hospital. So we're looking at this thing and we're close to coming into our second quarter. And we always budget, as you know, we always budget for the next fiscal year based upon the actuals of the first two quarters. Well, if we budget based on the first two quarters, I don't care what is set from an NPR, we've got a much bigger problem than that. I do see some light at the end of the tunnel in terms of improvement starting in March. Now that we've been doing 250 vaccines a day, people are coming back to the hospital, the OR volumes up, births are up. But I don't really know ultimately how we're going to end up for this fiscal year. So I'm trying to wrap my head around how are we going to approach this budget process with such an absolute unknown that, and I've been a hospital CEO for 40 years and none of us have ever been through anything like this. So I look at this budget process, I really appreciate everything that Jessica has said about if you've seen one hospital in Vermont, that's all you've seen is that one hospital. But I will tell you from the Brattleboro standpoint, to some degree it'll be a shot in the dark because we don't know where it's ultimately gonna go. And hopefully we get back to a better face in terms of volumes, in terms of revenues for FY 2022, but it's like a crystal ball right now. I think there's certainly be improvement. My concern is we don't see a lot of movement on the federal side. We got $11 million of CARES funding. If we hadn't for last year and if we hadn't gotten that, we would have had $11 million of loss unprecedented, certainly in this hospital's history starting out in 1904.  And there's some movement there, but as I said, there's just so much uncertainty. And I would hope that you all take that into account as you continue these deliberations. And I do appreciate the opportunity to share with you my concerns on behalf of the 600 employees here at Brattleboro. Thank you, Steve. And we have great expectations that the feds will come forward for the rural hospitals based on conversations that have occurred to date. But again, the proof will be in the pudding. With that, I'm gonna move to Dean French. And I think, Dean, that this is the first time you've spoken to an actual official Green Mountain Care Board meeting. So I'd like to welcome you. I've been very impressed with our meetings that we've had to date. And we look forward to your comments. Dean. Thanks, Kevin. I appreciate it. And as a relative newcomer, not relative, I am a newcomer to the state of Vermont, this has been an interesting journey in watching and listening to how we regulate and try to manage our healthcare environment in the state of Vermont. There are some concerning trends in the state of Vermont that predate the pandemic, whether it's decreasing margins across the healthcare system to the point of really threatening viability of some of our facilities. And also our overall outcomes as you measure them from an acute care hospital standpoint are not really trending in the right direction if you look at the high level metrics, whether that's CMS hospital compare metrics or not. And I would argue that Vermont should be leading, one of the leading states in the country on those types of things. And yet the trend is not in the right direction. And that's a change from a few years ago. As I boil that down to Northwestern Medical Center, I see that we're a microcosm of the same issues. We've had a lot of distraction and focus on areas that are really adjacent to our primary mission. And then you bring in the pandemic and so the points that all the speakers made are previous, they can't be understated, overstated sorry, what the real impact of the pandemic has been on operations at facilities. We like, my colleague at Southwestern have been an incident command nonstop. We've had, we're still have redeployed staff to support vaccine clinic, drive through testing, you name it. And I'm looking ahead at the budget process going, okay, how do we try to normalize our operations and regain our focus on access, on care coordination, on eliminating hospital acquired conditions and serious safety events and surgical site infections and get our observers' expected mortality back where it should be. And how do we get our patient satisfaction in the top quartile in the United States? And how do we decrease our cost per beneficiary? All the things that drive us to be a five-star CMS facility and in the face of a fatigued leadership team and a very fatigued staff. I think, there's lots of pressing needs in Northwest Vermont with our community, but we can't be the sole answer to our community's social ills. We should be a leader and a facilitator of a community-wide discussion about those social determinants of health that are barriers in Northwest Vermont. And ideally, I'd like to see where Northwestern takes a lead position in becoming an incubator and providing an incubation process for experimentation and how we start resolving our social economic issues that create the health issues that we see in our community. Having said all that, I wish that's where our conversations were more than they are currently in the regulatory environment. I really appreciate Jessica's thought process. A presumptive approval based on some high-level metrics would be remarkably useful this year. We are all tired and we could use that relief. So I appreciate your efforts as the Green Mountain Care Board and I appreciate my colleague's input. I hope I made some sense and I'll leave my remarks there. Thank you, Dean. I'm not seeing any more hands, but I'll put one more call out. Oh, I say that and the hand went up. Mike. Thank you, Mr. Chairman and good afternoon to the Green Mountain Care Board and the staff. I'm Mike Halstead and I'm the current CEO of Springfield Hospital. And many of you know about Springfield. You've been very attuned to what has been happening over the last couple of years. And I will be brief. I don't wanna appear to maybe be myopic in terms of just our particular situation, but I just wanted to give you a perspective. We did spend almost 18 months in bankruptcy. We are out of bankruptcy now as of January 1st. It was a result of a lot of hard work by people at this hospital as well as some luck. And it always takes a little bit of both of that, but we are out of bankruptcy now. And my perspective is, and again, it could be just this particular facility, with all due respect to the Green Mountain Care Board and what you're trying to do, I gotta tell you from my perspective, I don't worry about the NPR. What I worry about is making sure that our facility is operating at the lowest cost it possibly can because we are needed in this community. And we have to generate enough revenue to cover that cost. The unfortunate position that we find ourselves in is we have to generate a little bit more than just our cost because we have a commitment that we have to make to reinvesting in this facility that hasn't been done for years. And I don't know whose fault that is. I don't wanna point lame at anybody, but that's the situation that we face. And so my perspective is I'm not sure to us how important the NPR is. What's really important to us is to be sure that, and we work on this every day that our operating costs are sufficient to cover what we have to do here, what the community is looking for us to do. It's basic primary care, rural hospital type services that we're providing and that's all we're providing. And so that's my perspective and I appreciate you listening and I thank you for all the hours and hours and hours that you put in trying to do what you're trying to do for the state of Vermont. Thank you. Thank you, Mike. And I wanna publicly thank you for your service to the Springfield Hospital at a really trying time in their history and many people would not have predicted that you would have emerged from bankruptcy two years ago and you have and we all hope that you have a bright future. And so thank you for your service, Mike. I know you came out of retirement to make sure that the ship didn't sink and you succeeded in that mission so thank you. Is there other public comment? Isabel. Yes, good afternoon. I'm Dr. Isabel Desjardins, the Chief Medical Officer at UVM Medical Center. It's nice to have the opportunity to bring the voice and the face of the clinicians at UVM Medical Center to the Green Mountain Care Board this afternoon. I just wanted to perhaps contribute to some of the questions that were raised earlier when it pertains to the pent up demand or the expected pent up demand in the next year. We're seeing also lower volumes but we're also what we're seeing right now is people come into the hospital much sicker than they used to before. Our case mix index is gradually going up as well as our percentage of admissions from our emergency department has increased year over year very significantly and that is regardless of whether the individuals have are suffering from COVID or not. So we're seeing a 10% increase in the patients we admit from our emergency room to the hospital. So I highly anticipate an increase in demand in fiscal year 22 with a greater proportion of individuals that have complex illnesses that have not been addressed and come in with more complicated clinical presentations. So that's point number one. In terms of the COVID road ahead if you will, I do not believe that the impact of COVID pandemic is over from a hospital standpoint. We were the first to be impacted and we sure will be the last ones to get relief from the impact of it. With the vaccination certainly the morbidity of the disease will decrease significantly but the mortality will decrease significantly but I do not believe that the morbidity will go away. So we will continue to have to take care of individuals with COVID. The variant is an unknown and moreover we don't know what's gonna happen with the need for vaccine boosters and that's gonna be an other ball of wax if you will. I wanted to also build on what Mr. French commented on in regards to the conversations that is being taking place at this level in really not talking about outcomes of quality patient safety and levels of experience for all served in the system. What I've observed in the three years that I've served as chief medical officer is that the gradual narrowing of our margins over time is impacting our ability to maintain our clinical infrastructure and keep up with what is expected of us as a academic medical center. Really, this is not true 10 years ago but it is true now. Any investment that we're not making today is de facto putting us back three years in terms of keeping up with the advancements, technology, clinical expectations and performance expectations as an academic medical center. So I would ask that you take that in consideration in your framework for budgeting purposes.   People are fried and we need a break. So I think that I really appreciate your consideration for that. And it's been a tough year for everybody in the clinical realm. So thank you. Thank you. Is there other public comment? Yes, thank you. I just want to reiterate what the doctor just said specifically around the caregivers. I made a note in the chat box but I'll take the opportunity to say it. There's a significant unknown degree to which our hero caregivers are going to recover physically or emotionally. Studies are already showing high degrees of PTSD, moral distress and the long tail of disillusionment on the resilience spectrum. And so organizations are going to have to prioritize that work as well as the mental health needs of our patients in our community. So it's just going to be an added burden and I can't stress enough the profound impact on healthcare workers. Thank you. Thank you. And I see that Dale has raised his hand again, Dale. Yeah, the only reason I did that is because of the last two comments and I think I can add something to that as my daughter's family out in Colorado all four of them have had COVID or they either are over or still fighting it. And I was just talking with my daughter last night the first chance I got to really have a long conversation with her, what it's like to be a mom of a family that has had COVID. But her first comment was, I am scared. Like I have never been scared before and she doesn't know what to expect. She's asking questions like, do I get a vaccine three months from now because I've had COVID? What's the long-term ramifications for help for all four of them?  She has the same thing, no taste, no smell, burning sensation in the nose. She got strep and she had COVID at the same time. And yet she's trying to uphold and do everything she can. And one comment that really stuck with me is I have been so scared, more scared now than ever in my life, but I couldn't show it because my family needed me and I had to carry forward. That PTSD, I mean, I couldn't help but think of all the ramifications of what this is in terms of doctor's appointments, healthcare, going forward for just that one family that has had COVID that came home from school, nothing could be done. They did everything they could to not get it. She even shared with me that she asked the doctor, how is it when we took so many precautions, we got it and people that take less precautions didn't get it. And he said, disease doesn't favor what you do, it's just luck whether you get it or not. In other words, it can help, but it doesn't mean you aren't gonna get it. So those two people that just spoke, please take to heart what they said because I think they understated the issue as to what's gonna be coming at us. Thank you. Thank you, Dale. Is there other public comment? Hearing none, is there further board discussion? So I just wanted to share a couple of reactions and I have a couple of questions that I don't know who it would be appropriate for, but I would throw them out there. And that is to address Jeff's point around suspension of the process. For me personally, the level of uncertainty is why suspension just seems unrealistic. And I know you can certainly argue that because of the uncertainty, perhaps the process is less meaningful, but we do have a statutory responsibility. And while we certainly have the ability to tailor that this year because of our special COVID authority, I don't really think it was meant to extend to completely suspending the process. That's my personal opinion, having been involved in the legislative discussion. So for me, that was a step too far. In terms of simplification, as I have said repeatedly, I am certainly interested and open to that conversation. Here are the ways that I think we have already proposed in the staff recommendation to simplify. There's been a waiver in the proposal of the non-financial reporting into Dr. French and Desjardins comments. Usually we collect quality and have a quality discussion as part of the process, but in order to simplify, the proposal is to waive that this year and keep it strictly financial and not looking at access or quality in order to streamline. Second of all, the adaptive submission, which I haven't used adaptive, so I don't pretend to understand how complicated or simple that software is to use, but the current proposal is to keep that submission at the higher level, similar to the types of things that you're already preparing for your boards of directors, balance sheets, income statements, that kind of thing. And I very much appreciate the specific comments on the workbook from Mark Stanislav, because certainly I think if there were areas in the workbook that people felt like could be streamlined, this would be good information for us to have. No one other than Mark has provided that information. And then I think our current discussion around how do we set a trigger for a presumptive approval, I think is also an attempt. I would love to hear more what minimizing the Q&A means, because I'm certainly interested in that. I just don't know what that means exactly from a hospital perspective and how that would get memorialized in the guidance. So my question is, I would love to have more concrete suggestions around that. And I also just wanna thank both Mark and the folks at Gifford for the concrete suggestions that they provided in their comments, their written comments, because that was super helpful. Kevin, can I build on the Q&A component that Robin just raised, or do you want me to hold off on that? You can, I was just waiting to see if there any hands rose. Okay, yep. So go ahead, Jess. Okay, I was just thinking that my understanding is that the back and forth after the submission prior to the hearing can be administratively burdensome and onerous. And in light of all that we just heard from the hospitals and with respect to Robin's question about Q&A, I too would like to hear more about that, but I was gonna throw out a possibility, which would be, so hospitals that are submitting their budgets, the questions that would come prior to the hearing would be largely clarifying questions. If some data points don't tie out, if there's some misunderstanding, if our staff can't understand some component, it doesn't tie out to some tables, some clarifications, but other questions would be reserved for the hearing. But another thought would be typically our board members are the only ones that ask questions at the hearing. So, and the healthcare advocate, of course, I'm thinking we could roll in hospital budget team questions as well, but save it for the hearing. And that would eliminate some of the back and forth that happens in the between process. So that was a thought that I had that I was gonna bring forward to reduce some of the administrative burden, but it would require an understanding of what is a clarifying kind of question and probably involve having the hospital budget team involved in our hearing process more directly. So to speak directly to that point, this is something that I've expressed in the past in that questions should be posed to the hospitals upfront and what has happened too often is board members have chosen to ask new questions as at the hearing date and as follow-up questions. And that's what's really gotta stop during these uncertain times. This has to be a simplified process. It can't be the way it's been done in the past where people get a second shot. And I do see a hand up from a hospital that may be able to address questions that Robin and Jess have raised. So Claudio, is that your intent? Yeah, but it might not be the outcome, Mr. Chairperson. So I can't speak to the specifics. I can speak to the fact that as you heard from some of the folks here on the front lines, here at the hospitals, we've had to rethink and conduct our business very differently than we ever had before. We had to figure it out on the fly. If we didn't, Vermont wouldn't be leading the nation in figuring out how to do testing and how to get people vaccinations and arms. And the challenge is from our perspective with these resources is we kind of think, oh, once we get over, once we get to this point in time, we'll be able to take a breather and there's no breather for us. We are gonna go right from crisis to response to how do we now segue back to normal operations? And there's dozens, if not hundreds of decisions. We gotta figure out on how to restore those operations and our people haven't had a break. Judy Fox and the finance team have had no downtime. And now I'm asking her, Judy, at what point do we now close down the mass vaccination clinic at the Holiday Inn here in Rutland and bring it back in-house? Do some analysis for that. Judy, what do we do about all the pent up CTO time, paid time off that staff have? How do we manage that over the summer? When, you know, how do we do all these things? That's just what we're trying to say. And our own, I don't know the specifics of Member Lunge, but you know, my team would tell you, but my only appeal is that we would just ask the Green Mountain Care Board not to conduct business as usual in your oversight and regulation, like Tom said. We accept the fact that the structure's in place. We try to meet the guidelines and requirements and good faith that you put out for us. And I know Judy and I know the finance team, you put that out and it's gonna be hard for them just to say, oh, while we blew through that, it's just not how we're wired. So that's my only thing if you can just hear us. And, you know, this is an atypical year.  Will we be back at the same thing? We might. I don't know. It depends how this year goes. I know we're, but there's gonna be a tail on how we segue back into normal operations. Thank you, Claudia. Is there any other person that wishes to speak at this time, any board member discussion? Does any board member wish to make a motion or do you want to sit on this? Well, I wonder if we should continue through, well, I mean, I guess there's two ways that I think I could see this going. I think we could continue through the next steps of the slide and in the analysis the staff did around charge and then we could come back. And then, and also like the hearing parameters because if there is the will to do this concept that just put out there around, we set guardrails with presumptive approval. I think we need to have thought through all of those components together. So I think we could do that or we could start with just whether that conceptually is the way we're gonna go and sort of figure that out. I don't know. I'm open to moving forward in either way, whatever works for folks. But I think we should still, I think we have still have a little more discussion we can do today to get a little further along. Well, I think there's a lot more discussion that's gonna occur today. I agree with Robin. I think it would be good to kind of, I think some of these are go hand in hand. And I'm sure we're gonna have a similar conversation on do we do anything with rate or not? Do we look at waving meetings and what would those parameters be? So even though it seems like it might extend it, I think it might actually help us close it if we kind of go through those other discussions too. Let's hear it otherwise. I'm gonna proceed with Patrick's discussion of the next slides. Thank you, Mr. Chair. I was gonna suggest after all of the board dialogue and feedback that maybe we adjust our approach here slightly. So if it's okay with the board, perhaps we can navigate through the charge discussion and potentially enforcement and the exemption piece. And then you can wrap your conversation up to include MPR because I agree with the board members. I think it's all much closer tied than viewing it in individual vacuum. So with your permission, I'd like to proceed with that. I'll proceed. Thank you. All right, so with change in charge, as you remember from an MPR discussion, we do a lot of five year looks. So we wanted to encompass that over a couple of different variants here in dialing in the staff's consideration. Now we've had a lot of conversation here in the last hour or so. So I'm expecting this to change as well, but we were asked to come here with a recommendation. So we've done that for the board. So the first slide, this one and the next one you're going to see. The important thing to remember here is this includes UVMs approved commercial effective rates as we've known them over the last few years. So you'll note on this page specifically for fiscal year 21 that Porter has a 4% commercial effective rate approval. So what we're going to do is we're going to provide you a couple of different looks chronologically and then with UVMs effective rates and then with overall charge increases built in. So you're going to get a feel for the variability there. So as I stated, we have two looks here. We have fiscal year 17 through 21, which we have discussed has some higher rates than in past years based on COVID activity that the hospitals were budgeting for in 2021 or perhaps not budgeting for depending on the circumstance. So we've provided a five year average for that and a five year median for that. On the next slide, slide 13, we've extracted 21 in the event the board members want to say, hey, that was a one-off. It doesn't really impact my view of the decisions that have been made over the course of time prior to the pandemic. So again, this includes UVMs commercial effective rate but we are pulling out fiscal year 21 and we're backing up the chronology to 2016 instead. So 2016 to 2020 with UVMs commercial effective rates built in, you get a five year average and you get a five year median. So you can see the different approaches there as well. Shifting a bit, this slide and the next slide will follow that same chronological order inclusive of 21 and non-inclusive of 21. And this actually includes those overall rates. So again, as I discussed with Porter because that's an obvious example they had a 4% commercial effective rate and you can see here in 2021, their overall rate request to increase their charges was 0%. So we've done the same thing. We've applied a five year average and a five year median to keep consistent some of those recordings that we have done in the past and we feel that that highlights the various decisions across a few different iterations of the board but nonetheless, the data is in front of you. Again, here we have the overall rate and you can see how when we include those overall rates where zeros have been applied and 2020 is the end piece with 21 out. Those averages and medians come down significantly from inclusiveness of 2021. This piece here, we put in for board member, you suffered because she wanted us to show for possible discussion points, how rates shook out last year and because 2021 was its own special year for trying to approach budgeting and charges. We wanted to break this out for her in the event that she wanted to discuss this particular point further. So what we've done is we've provided for the board kind of the base rate and then the allowance that the board made an adjustment for when they rounded out the decisions. The whole picture is the combination of these two. So looking at North Buster Medical Center on slide 16, their total approved charge for 2021 was 13%. 10% of it was kind of a base and the other 3% was the board allowance that they gave on top of that. So continuing with our methodology here at the top on slide 17, you have your medians and your averages for the system and then we broke it out by hospital designation in the event folks wanted to see how it shook out across designation. And then we've broken it out with UVM's commercial effective rates built into those figures and then with the overall rates used. And we have adopted 17 to 21 from the staff's perspective because regardless of the fact that we may want to carve out 21, it does exist within the ultimate numbers when we look back at this historically. So we felt it was important to include that and you can see with the medians, there's not a whole lot of movement going on with commercial rates or with overall charges. The averages of course are affected because if Porter receives 4%, it's built into that average and if they receive 0%, it's gonna be ruled out as an outlier. So you can see some of the figures here as far as dialing in a data point. And so with that, we looked at those figures and our recommendation prior to this meeting today based on the request from the board would be a 4% charge ceiling as we left it last week. And that considers the rates approved in 21 using the median charge request to remove those significant outliers where they exist. But we also wanted to add a couple of other options that maybe you choose to designate a ceiling based on the hospital's designation of critical access or perspective payment. And that we have dialed in based on that information at 4% or 3% or 5% should you choose to accept it. And then also as a final option, and this has come up already in this discussion is making the change in charge ceiling only for those hospitals who may want exemption. So you could set that ceiling and then let everyone else bring in what they want but those hospitals who accept the ceiling that you've put forth, that would be one component towards the exemption policy that we'll talk about in a little bit. The next piece here is we have a standing enforcement policy. There's been no changes on that as legal discussed last week. However, that may also dovetail into your logic as you think through your NPR, your charge and your exemption policies because ultimately enforcement can be a component, regulatory component within all of that but with all of the unknowns that have just been discussed here today, it's probably pertinent that that gets woven into this overall discussion and isn't particularly done in its own vacuum. So part of that is it is standing enforcement policy and the board may adopt that policy still and waive enforcement at a later date. So if you choose to accept the policy, then it is in place and that you can make your decision at another point in time on that particular component of the discussion today. So moving forward to the exemption discussion, we've put up here on the screen some of the considerations from the current existing exemption from hearing policy. And I won't read through all of these because they've been posted and board members have had a chance to read through them but we wanted to put them here as a point of reference as we work towards the next piece which is the staff recommendation based on the discussion around exemption from last week's meeting. However, before we get there, I'd like to turn it over to a member of our legal counsel Russ McCracken to talk about process because there are some items here when we get down to staff recommendations that may need to be evolved with the existing process.  So I'll turn it over to you to discuss the process around public hearing and some of the recommendations we have below. Thank you. I will just briefly here frame how a potential exemption process would work within the existing rule and the authority that the board has. I want to note that under rule 3.304, there is an existing procedure for exemption to public hospital budget hearings but the way that rule works and the limitations included in that are likely too limited for what the board is looking at here. Specifically, the rule says that only four hospitals in any year can have their public hearings waived and none of the four largest hospitals in the state can have their public hearings waived. They're simply not eligible for that process under the rule. So to move away from the limitations that are contained in 3.304, the board could utilize its Act 91 authority to create an exemption process to waive parts of the rule to ensure an orderly regulatory procedure here. Specifically, it would be getting rid of those two limitations that are noted on the slide and also setting up the additional criteria for having exemption to the public budget hearing. Last note here, an additional note here, hospitals that are exempt from the hearing will not have their budgets adjusted and as a point of clarification on that, the language you see on the slide comes from rule 3.304 and it means that if a hospital submits a budget, meeting the criteria set by the board for exemption, the hospital would not be required to have a public hearing and the board would not order any adjustments to that hospital's budget. In other words, that the hospital budget would be approved as presented. And just to clarify, it doesn't prevent a hospital from subsequently asking for a modification to its approved budget as hospitals would typically have that ability to do and using that normal process. So Patrick, do you wanna go through the proposed criteria or would you like me to do that? No, I'm happy to do that. Thank you, Russ. So we lead off our criteria here at Peace with something that needs to be considered that we really couldn't do without Russ's discussion and the board's Act 91 authority. So that's considering whether the exemption would be open to all hospitals or whether the largest hospitals should have their hearing. So that's as part of our recommendation couldn't really be a factor based on that process that still is yet to occur. So with that, you'll note that the MPR rate request and charge increase request, what we've put in here are our recommendations following the discussion today and a couple of other financial metrics as we heard from board members last week that they might wanna consider as part of this would be, as we've laid out days cash on hand at or above the median for the system. So we wanna understand their liquidity and ability to absorb perhaps some ups and downs as has been discussed here today and also whether or not their operating margin can be budgeted to a positive. And yes, we understand that there's so much unknown out there budgeting is going to be a near impossible request but if the board were to adopt this MPR and charge increase can the hospital still come into the positive market? And that's out of consideration for their ability to operate above water for the year. In addition to that, we would like to see continued involvement and value-based care reform and we put not limited the ACO. We are understanding that hospitals do have other value-based contracts and we think that is valid, that are not operated within the context of one care for month. And then we have some items up next around the budget assumptions are deemed reasonable. That comes out of the existing rule, budget submissions reconcile and the content complies with guidance. So those all come out of that initial rule in either exact terms or lesser than exact terms. And then finally, from a logistics perspective, we would need to decide as a regulatory body what the deadline for pre-approval would be and we're floating the July 28th deadline around when the staff normally with last year's exception presents the budget submissions to the board. You have rate review to consider in the month of July and we certainly don't want to overload that process but we usually have a placeholder on late July to present the preliminary budget presentations to you and that may be an opportune time so that we have enough advanced notice for the hospitals you may want to exempt that they don't have to prepare their presentation for mid-August. So we wanted to take that into consideration as well when making this recommendation. And that ends the discussion on change in charge, the enforcement policy and potential exemption and the rest of the language here is around potential motion language for the exemption and the overall guidance, but we'll turn it back over to the board to discuss those topics. So thank you. And maybe it would be good if we just took a straw poll at this point in time on whether or not there's interest by the board to allow for the presumptive approval process which would require using language under Act 91 and waving aspects of the current rule that is in place for that waiver of hearing. I for one would support a process that would allow for a waiver of hearing. I would not support a process at a 4% threshold of change in charges. I think that's too high without having someone come in and explain why they need that. And so, but the concept itself I'm not opposed to and I'm curious what other board members are thinking there. So I could support a process that is very truncated in the near term. It's clear to me that there is so much that we don't know that we have tired troops out there in the field and that we should as much as possible kind of use this process to establish some performance standards that are important to us in terms of affordability, the NPR number in terms of solvency, day's cash or margins or for me reform an FPP number so that we're basically kind of looking to the future which is very foggy at this point in time but we're looking to the future and saying these underlying metrics are important to us but we don't have the information and the certainty that we need to make more nuanced decisions. And so if we were to say here are these performance standards that we're looking to and if a hospital will agree to those which kind of shapes the forward view, then we would allow without a lot of work on the part of the hospital to get whatever increase we decide is where we wanna go in terms of NPR and some basic thresholds having to do with solvency. So I can't see any rational way out of the situation that we're in now in terms of using an information process and a hearings and all of the requests that we've made of hospitals that's gonna get us much. We need more time for things to sugar off. And so, but we also have to abide by the fact that hospitals need to sit down with the insurance companies et cetera, et cetera and negotiates. So if we're in a 3%, 2.5%, 3%, 3.5% world let's just keep it simple and go with that understanding that it's a placeholder until we get to a time forward where things are more clear. Other board members? Well, I'll jump in and I think I'm supportive of this, this presumptive approval process. I would limit the parameters to the rate request, the NPR FPP rate request under a particular ceiling and the charge increase request. I would add, I guess I would add that the operating margins should be budgeted as positive. I agree with that point. My concern about the days cash on hand at or above the median for the system, by definition, if I understand that means that half the hospitals would be ineligible if that's a criteria to be included in this. So if we wanna look at days cash on hand, I think we need some absolute number, not a median number because half of them will be above and half of them will be below. And if we're using that as a criteria, we've automatically just assumed that half cannot participate. So that one doesn't quite work for me, but I'm supportive of it. I think what we decide on those parameters will be the next part of the conversation, perhaps if others agree with this process. But I think in this era of uncertainty, administrative burden burnout and all that we just heard, I think this is a way forward. Other board members? Yeah, sure, I'll go. I can get comfortable with waving the meetings, although I would put in their submission if a hospital wants to come in, it's approved if they hit these parameters, but if they want to come in to meet with us, and I think some may want to come in to be able to tell their story, to be able to talk about their risks and opportunities and things like that. I mean, my preference would be that they do and that we give them, that it's like half the amount of time that we normally would have and that they know when they come in, it is they are approved and I think we're still gonna be zooming, so it makes it a little bit easier, they don't have to drive. But if people didn't want to put that in and didn't feel strongly about that, I can get my arms wrapped around on the full waiver. Just one point on the charge, which I know we'll discuss in a bit. Last year, the lowest that was approved was 3.2 by Grace and everybody else was at or above 3.5. So we may think four is high, but if we're gonna get into that waiver range, I think it's gotta be 3.5 or north of there because nobody would have qualified last year. So I think we just need to look at that and I know last year we had some issues, but we still have those issues going into next year. But we're gonna get into the rate discussion so we don't have to line on that. I just wanted to make sure everybody knew where things shook out last year by individual hospital. And there were several that we approved straight up what they requested, but those were all in the kind of three, six to four range last year. So just as a data point, but I think we should at least put the option that if a hospital wants to come in with this, they can, but it would be approved. Maybe we don't require that. I'm also okay. We always look at the days cash on hand and the operating margins and things like that, but that hasn't as we've been the driver in our decision. So I'm okay with not putting those in a waiver because I think in a hospital might come in with a, they maybe they have a negative operating margin, but it's because they received, maybe a budget of negative operating margin, but it's really, but their balance sheet looks really strong because they got some money and they didn't have to pay it back and it put them in a stronger position. And so for some reason, maybe they would be negative, but I think the intent of all the hospitals, and if we look historically, they do budget for a positive margin. It ends up being negative for other reasons. So the budgets, the budgets probably would all be positive, but at the end of the day, we'd be back looking at what really happened and when many of them go in the red, it's not because that's how they budgeted it. So just to jump in on that Maureen, the reason why I don't think a presumptive approval should be granted on 4% is exactly the point that you brought up that last year, they were higher than that. The reason why many were higher than that last year is we aired on the side of sustainability. We needed to keep our hospital system afloat and originally we had intended to have a bifurcated rate because of what took place in Washington, that plan quickly changed and everything was turned into one rate increase and to give 4% presumptively without even going through the thorough review and discussion on top of some of those that came in high last year, I think is just inappropriate because again, it just moves that base higher moving forward and will always be baked into the system. Yeah, and I do think when we get back to the charge discussion, there is that topic of what consideration, if anything, do we do for those hospitals that got extra above even a 4% rate last year, but who ended up getting some COVID, what we would consider COVID-related extra money, but that's okay, I guess we can defer till we talk, get out of people's perspective on rate as well. Okay, I think the only one who hasn't weighed in yet is Robin. Yeah, as I've already said, I like the concept of the presumptive approval and hearing waiver, like Maureen, if people wanted to come in and talk, understanding that their budget was already approved, this was just informational, I'm fine with that, but I would leave, as Maureen said, that up to the hospital's choice. And Patrick, can you go back to the previous slide with the parameters? Oh, sorry, it must be more than one, there we go. So I think the other piece of the criteria we need to sort out in addition to the metrics are some of these other pieces, and so I would personally have the exemption open to all hospitals, because I think everybody's in the same boat this year with the exhaustion and uncertainty. And I'm kind of open on the other metrics. I can see why having, to Jess's point, I think it would make sense if we do include day's cash to have it be an amount so that we're not presumptively taking it off the table for half the folks. So I could see two things, either having those two pieces in or excluding them, but understanding that in our monitoring, if things were looking worrisome, like with anything we would ask, we would call people in to really talk through about anything that was worrisome in the reporting. So I'm not sure where I land on that yet. I'm interested in other people's perspective on that. To me, the two key pieces are the NPR in charge. And I think the 28th, that sounds good to me since we would be doing preliminary budget presentations that time anyway, although I'd love to get some feedback from the hospitals in terms of the timing of that versus when they would be preparing their presentations and that kind of thing. So I guess to summarize conceptually, yes, I could apply it to all. I'm not exactly clear on the specifics of the metrics other than NPR in charge and the 28th looks good. So thank you for rounding out that discussion because we kind of glossed over some of those other points. And I think it is important that we weigh in on those other points as well because like you, I believe very strongly that if one hospital is given the opportunity, all hospitals should be given the opportunity. And so I think that we would need to wave our own rule when it came to that. And I think that's very important. I do think that the July 28th deadline is important because anything beyond that really would be unfair to put so much pressure on already pressured staffs to prepare for a hearing. And it's not on this particular slide, but one slide had proposed possibly having different rates for PPS versus cause. And the reason why I don't support that is as you look at what the charges are for a number of procedures around the state. And this was highlighted in a Burlington Free Press article recently, some of the most expensive hospitals are critical access hospitals and they're expensive for a reason. They're expensive because if you're in Newport it's pretty hard to drive someplace else. And so even though they don't have the volumes of other hospitals, past regulatory decisions have deemed that it's essential to that area and have allowed for those higher rates to be charged. And so, but to give a blanket, higher presumptive approval increase to critical access hospitals across the board I think is a mistake based on the fact that some of them already have some of the highest charges. And I think they have to come in and talk about why they would need that. And it's important to have that conversation. So I would not like to see different rates between the types of hospitals in terms of allowing for that presumptive approval. Other board members? I agree, Kevin, that it should be open to all hospitals not just a subset of them. The 28th is perfectly fine with me. I would consider a flat rate as well. I don't think we know all the implications of having a different rate for PPS versus critical access. We just haven't gone down that path and I wouldn't want to do that on the fly. So I hope that that answers. And I think for the rest of the criteria here in terms of budget assumptions are deemed reasonable, budget submission schedules reconciled, budget content complies with guidance. They all seem fine to me. Yeah, I'm okay with all those other components as well and not doing different rates for different hospital classifications. I'll throw out there that one thing that could be done under the charge increase would be considering hospitals that did get incremental last year, maybe they're 1% less or something like that. So it is taking some type of recognition for the fact that we gave higher rate the year before with the intent that it may be temporary and this is for the waiver process. So just something to think about there. Do we give everybody the same or the seven hospitals that received extra money for COVID and for the most part, which was two, two and a half, 3%, do we do some type of consideration to say it's 1% less? And I think that the reason I throw that out there to kind of balance is a little bit of fairness into what hospitals received this year. Some of them were very high and then if everyone were to get the same next year to start off for a waiver process, is that the right thing? Or do we want those hospitals to come in? So I would just throw that out. Other board members, is the preference to take a stab at a motion today or is it the preference of the board to mull this over and come back next Wednesday to try to get through all the remaining pieces? I would love some public comment on what we just discussed. And that I think would help me get to a point I mean, we may be able to get to a point where we can at least vote on the structure, meaning the presumptive piece who we're just discussing even if and without necessarily filling in the blanks for the NPR in charge, which may be sort of the harder part to come to consensus on. See, I just have a contrarian viewpoint on that Robin because there's no way that I would support a presumptive process if the charge was higher than I felt was appropriate for. I think that a presumptive approval requires less than what we envision the over