It looks like we have everyone, so I'll call to order the Green Mountain Care Board's hearing of September 13th, 2023. On the agenda today, we have deliberations. Including the University of Vermont Medical Center. Central Vermont Medical Center, Porter Medical Center, and potentially Copley and North Eastern. Although my understanding is that we're very unlikely to get to Copley or North Eastern and there's some continued staff now if this is going on relating to those 2. If I don't anticipate, we'll get to those. We'll also have the standard budget order conditions and the potential vote is noticed on those. So, I think we'll start with the medical center itself. And before we get started, I wanted to announce, I think a lot of people know already, but Director Lindberg will be moving on from the care board on Friday, Friday is your last day. As everyone knows, she's had a tremendous career here and we'll give her a proper send off on Friday. She could have left earlier. Obviously, her future employer wanted her services as soon as they could possibly get their hands on them, but she did the care board and stayed a huge favor by staying on and getting us through the hospital budgets. And not only that, she's been working day, night and weekends and really her dedication has just not let up. So I want to thank Director Lindberg for that. We also are fortunate to announce that Elena Barabee will be the future Green Mountain care board director of health systems finance. Elena has been with us in the past. She used to be a director of the health policy team and she's currently working on her PhD at Dartmouth and she has stepped up to partner with Director Lindberg and the hospital budget team throughout the summer. And has really taken on a huge load and the huge thank you to Elena for jumping in like this and we're really, really thrilled to have such a talent and such a bright future with our hospital team. So thank you both. Mr. Fisher. Just a process question. I don't see the slide deck up yet. I don't know if it's on its way, but would love to see it on the webpage if possible. Yes. I'm sorry. This is Laura Pagan. I am working on the upload now. It's just a little time because of the internet and me being connected to the presentation as well. Thank you. You're welcome. Right. So I'll turn it to Director Lindberg and Miss Barabee. Okay. So my team's instance says I'm sharing my screen. Does anyone else see slides? Okay. Great. Okay, button. All right. Let me just stop and restart if that helps. All right. Any luck this time? All right. Fantastic. So good morning for the record. My name is Sarah Lindberg, the outgoing director of health systems. Long thing. I never figured out the title. Health, director of health systems finance. And we'll be joined today by Elena Barabee as we already covered in Russ McCracken, our staff attorney. So the agenda for today is we'll spend a moment just regrounding ourselves in the process that we're using for hospital budget review deliberation this year. We will deliberate on the University of Vermont Medical Center, Central Vermont Medical Center in Porter Hospital, which comprise the Vermont contingent of the University of Vermont Health Network. And then we will have a potential vote on the standard budget conditions. We will have a short recess between those two agenda items to offer a chance for board member Merman to rejoin us for the standard budget condition presentation and vote. We will not have a chance to address the final two hospitals until Friday. So appreciate everyone's patience in that process. So the general approach we took this year is for each hospital budget submission that came in, we stopped to evaluate whether or not they were able to meet the benchmark for net patient revenue growth, which was at or below 8.6% growth from fiscal year 22 actuals to the fiscal year 24 budget. There were two hospitals that were able to do that and they were approved without modification. And for those that were above the board is evaluating and weighing several factors as they consider modification such as the reasonable of the budget assumptions. How each expense factor compares with reference ranges, the expense growth and its comparison with peers. What it looks like compared to projected inflation is measured by the Medicare market basket and wage growth. Other factors and criteria is established in the guidance and statute. So this is the side of the tree we're on, the no side. And so we are here to talk about the University of Vermont Medical Center. So I will change over to the summary of the information so far. So zoom in just a little bit here. So as you see, there have been some very slight modifications to submitted NPR since fiscal year 18. Some of those hit both NPR and the commercial rate. But last year there was a adjustment to the commercial NPR, but not to the NPR. And we see that in recent years, an increasing reliance on the commercial rate. So that is how much the increase counteracts or interacts with the amount of commercial gross revenue in the payer mix. We also see that like a lot of hospitals that there were unfavorable operating results in fiscal year 20. However, it does look like those have rebounded pretty healthily in the case of the medical center. As far as expense growth factors, the growth in compensation per FTE was 3.9%, which was the seventh highest right in the middle among Vermont hospitals. The utilization assumption of 8.2% was quite high and a little bit above the median and certainly above the benchmark range. I think increasing utilization and addressing access is a good thing. So from a staff perspective, that's not a number that gives me pause and is encouraging that they've been able to realize that. The pharmaceutical expense growth at 30.7% is quite high, the very highest among our Vermont hospitals. There are only seven of the 14 that break out this expenditure, so they're the highest at seven. They also are one of the only facilities that offer some of the more expensive and other pharmaceuticals. So they were able in their record to kind of explain their approach to that and help us try to understand how much of that actually affects what is asked for in their rate increase, which is not by no means that entire amount. As for cost inflation, they're at the fifth highest at 3.7%, which is right at the median. So that seems to be in line with what we would expect. I think it's important to note that as compared to the fiscal year 23 approved budget and the year-to-date results, we're seeing a more favorable operating margin and operating a bit of margin and total margin that was budgeted. So despite the rate adjustment that was made last year, it seems like the 14.77% granted last year is helping them to recover. And we see that the budgeted amounts for fiscal year 24 are largely unchanged, seeing a little bit of a dip in cash and that's a little bit lower than we ideally would see in a healthy financial outlook. As far as the ratio of administrative and general salaries to clinical salaries, in the cost reports as filed, this proportion is 31%. However, the network in one of the letters, they responded to our questions to adjust that to better allocate the shared services across the network. And so to make sure to kind of try to address that, we have adjusted that here to 24.36%. In all honesty, I was a little on the fence about that because not everyone on that list had the luxury of kind of doing that exercise. So I think that's definitely an opportunity for future work to make sure that we can measure that in as apples to apples away as possible. After that adjustment, it's the ninth highest ratio for that indicator among Vermont hospitals and is at the 71st percentile among their comparators, which is the Association of American Medical College Hospitals. The CMI adjusted average cost for Medicare discharge is at $14,277, which is the 12th highest among Vermont hospitals and is the 83rd percentile among their peers, so above the inter-core tile range. The relative pricing looks a little bit different since the only comparator we have is Dartmouth Hitchcock or Mary Hitchcock Hospital. So what we see here is a pretty stable trend where the cost commercial cost per discharge is higher at DMH or at Dartmouth as compared to UVMMC. However, UVMMC and Dartmouth had pretty similar cost coverage ratios up until fiscal year 22 where we do see that UVMMC had a more favorable cost coverage ratio than Dartmouth. We also see that for the standardized price on the inpatient side, UVMMC is right at the median among major teaching hospitals. However, when we look on the outpatient side at 351, they're above the 75th percentile on that standardized commercial price. As far as the comparison to Dartmouth on outpatient, we see that the relative cost coverage is quite a bit higher at UVMM than it is at Dartmouth Hitchcock. If the hospital were underfunded, that's not necessarily a trend that I would expect to see, so I think at least on the outpatient side it seems like the commercial cost coverage is adequate. Any questions about the deliberative summary before I turn back to the PowerPoint presentation? Are you seeing University of Vermont Medical Center budget request? All right, wonderful. So here we're looking at what the fiscal year 23 approved budget was, which was $1.7 billion, which was a 10.8% increase over fiscal year 22. The budget submitted for 24 is $1.8 billion, which is a 7.6% increase over the fiscal year 23 projection. When we look at the two years from the fiscal year 22 actual to what was submitted for fiscal year 24, it's an increase of $356 million, which is a 23.8% increase. As far as the commercial change in charge, or not, I'm sorry, the change in charge applies to all payers equally, that would be on the gross, so it doesn't matter who the payer is. But the charge master increase has been 10% for both of those years for a two year total of 20%. The University of Vermont Network Hospitals do have a different metric they submit called the commercial effective rate. So the way that works is they tally up the cost inflation that they have experienced and that was not covered by governmental payers and they figure out how much of the current commercial reimbursement is needed to cover that cost inflation. And so the board approved 14.77% in that effective rate increase in fiscal year 23 and the network submitted an additional increase of 13.45%, which is a total growth of 28.22%. The NPR growth is the highest among all the Vermont hospitals and the change in the commercial rate is on the higher end of those submitted for the two years. If we were going to look at how these factors compare with seven year inflation over two years, that would be a $226 million reduction for NPR or about 10.5% decrease. And that would only be achieved with a negative 7.8% change in the commercial effective rate to get to 7% over the two years. If we were going to only apply the 3.1% in Medicare market basket to the commercial effective rate, that would bring the two year total to 17.87%. So that's pretty close to the top end of what we've been seeing in this two year period. And just, I think, is a testament that they got a little bit higher rate last year than some of the peer hospitals. And that reduction is $119 million or a minus 5.6% reduction in NPR, if it were applied there. Looking at this performance summary, the expense growth at 15.3% is at the 96, 92nd percentile among Vermont hospitals. That adjusted proportion of admin and general salaries to clinical salaries is at the 71st percentile among their peers of Academic Medical Centers Association thereof. That Medicare CMI adjusted cost per discharge at the 83rd percentile we just covered. And as we just mentioned, the standardized price spring patient is right at median, but the outpatient is at the 84th percentile. So here for the rate changes over time, we're looking at that commercial effective rate. So over the five year period from fiscal year 19 to 23, that was just under 37%, which is the 92nd percentile among Vermont hospitals. If you were just to look at charge increases, they're at the 62nd percentile. We don't quite have 10 years of the commercial effective rate, but nine years of it is at 53.8%, which is also at the 92nd percentile among Vermont hospitals. But the charge percentile is much lower at the 15th. Just want to say that we are seeing a notable change in operating results since the rates that were approved in fiscal year 23 went into effect. So just seeing that recovery is really starting to materialize in the operating results through June. Don't have anything more recent to that, but seems like that is translating to some more beneficial operating results. And with that, I will turn. Oh, yeah. The rate changes that went into effect from last year's budget decisions. Okay, those start in January. Correct. And are they all effective January, or is there like a lag or they all become effective on the same day to our knowledge? I don't think that every single group would renew on January 1, but the lion share of rates do go into effect in January 1. Okay. All right. Thank you. Sorry. Sorry. Oh, no, not at all. And with that, I will turn it over to my colleague. All right. Okay. Sorry about that coordinating. So that will keep driving. Thank you. So I think in effort to understand the magnitude of the change and thinking about opportunities, we kind of dug deeper this subsequent slides are not exhaustive of revenue or efficiency considerations, but wanted to highlight a couple that that kind of came to our attention through the process. So the first one is casemix index. So there's been robust discussion about how Medicare reimbursements for UVMC have historically been low compared to relative peer groups, citing the atlas and other sources. And then in its 817 letter, the hospital discussed its recent implementation of iodine and a software technology that will augment DRG coding. And this will lead to higher acuity of patients being reflected per the EMR. And this has implications for kind of the magnitude of the reimbursement from Medicare, but also potentially from other payers. So while the Medicare estimates were communicated to be around, you know, to go up to 2.3 from a 2.06 in FY 22 per the Medicare costs reports. You know, it's unclear kind of how these, but the impacts are further than this. So we, the staff requested further information to understand this impact. And UVM was responsive. So you can go to the next slide. But there still remains a lot of uncertainty about kind of how these estimates were derived and how comprehensive the impact is. So we understand that the methodology for for estimating the potential revenue opportunity cannot be shared. They did share however, how they got from kind of the 23 Medicare CMI to the future Medicare CMI of 2.3. But it's unclear kind of what is included in the budget versus what this potential future state could be. And then in addition to that, it wasn't super clear, you know, the magnitude of the impact on some of these other private payers. We did receive a public comment from Blue Cross Blue Shield that estimated their impact to be around 11 million because they do have some DRG based methodology. So this, so assuming this algorithm is, you know, done across the board for all patients, you know, it would have this impact. So this is what we know or we know of estimates. So it sounded like the Medicare impact would be around 20 million. Blue Cross Blue Shield impact would be around 11 million. Again, it's not clear how this, you know, deviates from inpatient, outpatient and kind of the full scope. There's likely an impact on Medicaid, MVP, other commercial payers, you know, to the extent that bad debt and free care. I don't know how those estimates are derived, but if they're attached to DRG methodologies, there could be an impact. So at the very minimum, there could be a $31 million impact and we really don't know what the total impact could be or over what period of time. So we understand that this technology has been implemented and is starting to ramp up, but it'd be great to know how things are going and what that will look like for next year. Okay. This is another point of conversation that has gone back and forth on the sale of investments. So we understand that there was 61 million of financial gains, only 10 million or realized. So depending on how the market continues to go up or down, there, you know, could be a potential for some more opportunity there if you need to plug a budget. So we could go to the next slide. In addition to that, there does appear to be some unanticipated net income. So while the approved margin is around 2.4, the FY23 projected margin is coming in at 3.8%. So that was that slide Sal showed earlier. If you put this in dollar terms and that should be sorry, October through June is around 41 million and the approved versus actual is around 25. So if you annualize this, that gets to kind of almost 83 million or 50 million. In addition, there appear to be some Medicaid rate increases in New York around 7.5% that are not reflected in this budget. So that could theoretically decrease the impact or the reliance on commercial rate. They estimated this to be around 2.2 million, but it'd be great to understand if these rates were approved or how that might affect the rate. In addition, operating expenses do seem to be outpacing inflation. So if we look at the two year at 7%, that puts us over 7% all hospitals, UVMC 8% and the other hospitals between 3 and 10. If we look at the median relative to median relative to other Vermont hospitals, we are between 2 and 9% for these hospitals. We also dug into the shared administrative services. So I wish I had more time to organize this in a way that would be easy to follow. So I'll do my best to explain it. So I think in the record, the hospital indicated that they were at median based on the Sinteles benchmarks, which is an external data source to allow hospitals to understand how they're operating and admin expenses compared to peers. There are a lot of assumptions that go into that. So here we only have information on Vermont hospitals, so we're not able to do kind of a comprehensive analysis with the New York data as well. So I've varied kind of based on at the high level at this top box, I used a 84.6% Vermont share of business based on UVM submitted gross patient revenue. And in the box below, I assumed a 77.6% share between Vermont and New York based on the fiscal year 22 Medicare cost reports. So that is kind of a more conservative approach. So if I use the FY 22 Medicare cost reports of that bottom box, it does look like an aggregate. The hospital is kind of at median compared to peers. However, that would assume that the operating budget in Vermont is efficient because that would be the denominator. So if you look out to the right, if we assume the operating expenses should grow with two year inflation, this would put them at a higher median. Higher than median for their shared admin expenses. If we compared and I didn't again have time to build this out totally, but if we compared to kind of median hospital OPEX growth in the state that would also put them over the median. So I took the most conservative approach assume that they were at the median for shared expenses and can go to the next site. But when you look at kind of a line item detail, there are a couple areas of admin shared expenses that look a little bit high. So human resources about double that of peers, IT is almost two and then revenue cycle was almost four times what peers spend. So this is kind of a subset of what was submitted in their budget. Again, this is using all of their data just kind of trying to understand some of the assumptions that go in there. So despite conservative assumptions, it looks like so this was the assuming everything on this page assumes that their admin expenses were at the median and that an aggregate they're appropriate. Given the operating the submitted operating budget. And so it looks like there could be some opportunity here to to get back to to median. So I quantified that amount given the conservative estimates and that puts EVM to another, you know, 91 million that could come down potentially. Okay. All right, I'll turn it back over to Sal. Did I do it? Can you hear me? No echo. Okay. Wow. All right. So the staff recommendation here and our recommendation would be to allow the required NPR and FPP growth as budgeted at 23.8%. However, we would recommend adjusting the amount of that revenue that could come through price down from the 10.0% change in charge down to 3.1. There also is interest in including an additional condition for monthly monitoring and to submit within three months and improvement plan addressing some areas of particular concern. The rash now for this is that it would bring the two year growth closer to peers in Vermont. The fact that the current peer to date performance results are outpacing the budget leads us to believe that that some of those continuing results are likely to continue to manifest through the rest of fiscal year 23 and beyond. And seeing that the relatively high as defined as being above the 75%ile and expense growth cost per discharge and admin to clinical salaries suggest that there might be opportunities for efficiency to help keep these numbers whole without such high reliance on the rate increase. So that's what I have to say for the moment.  Thank you. Is there a motion, a draft motion? I will open it up to board member comments and questions. Also ahead and jump in first. Sarah, could you speak a little bit more to the rationale for maintaining the NPR growth at nearly 24% over two years? Absolutely. I think as we covered, I think we're all concerned about some of the access limitations. And so I think that allowing there to be incentives to increase utilization and address some of those access issues, as well as some of the other opportunities to increase revenue without it being based on a price increase, such as some of the CMI optimization. I mean that that growth probably is appropriate and warranted, but trying to balance that with the toll it takes on commercial repairs is what we're trying to balance. Thank you. That was my only question. I do have a couple of comments in terms of how I'm thinking about this hospital and its budget. So I am supportive of ensuring that the state's only academic medical center and the Chinden County's community hospital have a financial stable platform to operate at a price that commercial, commercially insured patients can afford. I'll note that it is concerning to me to have an NPR growth of 24%. However, given the access issues and the opportunities there for ensuring that more patients are able to be seen in state at our academic medical center, I will support it. I would, however, note that this is an unprecedented NPR increase over a two year period, at least looking back to the data that I could find in our 2023 annual report. The next highest prior to COVID, recognizing there's some COVID confounding more recently, was in 2005 to 2007, which was about a 17% NPR growth over a two year period. And if my recollection serves, it was at that point that the state legislature actually stepped in and capped NPR overriding the regulator who at that time was banking insurance securities and healthcare administration. However, access is a big deal and I think there's a lot of opportunity to improve that and keep for monitors in state as well as many of the other items that you both discussed today. I am also comfortable with the 3.1% charge increase. Last year's rate increase was large. We are seeing that adding stability. In this year's margins, which is good. And I think allowing for an inflationary increase is necessary as well. I would just note that as the board discussed in a great detail in 2019. Overreliance on commercial rate as a way to ensure financial stability is problematic in a state with our median household income. And this is why we sought legislative support for. Looking into sustainability. And how we as a state as a whole. Can ensure that Vermonters can continue to access services in their home communities. To the greatest extent possible in an affordable manner. There are I think opportunities in addition to access that can be pursued. By any hospital and I have faith that the talented management team at the network will be able. To do the work that's needed to find those opportunities and take advantage of them. Lastly, I would just note that last week the center for Medicare and Medicaid innovation announced a new payment reform initiative called the ahead model. As which is a model that a state like Vermont could consider pursuing. Part of that model includes global hospital budgets, which require new and creative ways of thinking about financing. Hospital services and increased focus on expenses and health improvement. And I mentioned this because I think that that will be a culture change for all of our hospitals. And I'm hopeful that given the network's focus on population health is evidenced in their information around. Their efforts to standardize that across the network that they could be a leader in moving forward with that creative thinking. So those are my thoughts. Thanks. Thank you. Other board members. Cheryl, I'll go chair foster and thank you member lunch. I've grown comfortable with the 23.8% increase in NPR for reasons mentioned. We have an access issue in the state. We have a backlog of people needing primary care appointments. We have severe need for more mental health services substance use services. We've had a worsening and rapidly rising crisis with suicides across the state. There are a number of areas that deserve greater attention that would need more utilization of care. So, allowing for that much growth I've come to be comfortable with. I'm still struggling with the 3.1% increase in charge. I think it could be lower. I think given the information that's been presented today and reviewed over the past few weeks. There's a sound argument data driven evidence based to cut rates. So I'm eager to hear what the remit what the remaining board members have to say. I'd like to also as Robin did make a comment. Through my career I've worked with hospitals across the country and seen a number of them under financial stress. Hospitals under financial stress across the country take several predictable steps. Their executives voluntarily cut their salaries. They decrease administrative layers. And they put off infrastructure projects all in order to maintain services to patients. Our hospitals are not doing that. They're investing in additional administrative services called shared savings or shared resources that are supposed to produce savings. But if not, they've ballooned the administrative layer. Our hospitals are moving forward with infrastructure projects at a time when. They're telling us they don't have enough cash on hand to maintain services. Our hospitals are also attempting to intimidate the regulators. While saying that they'll be forced to cut services because their finances are in trouble. The review of data that we've seen our hospitals do face some headwinds, but nowhere near like others across the country. Our community and academic medical center takes pride in being the only one in the region. And they should. We have an aging population more people moving on to Medicare. We need an academic medical center. We need a community medical center. But this is also a little bit like being the only ice cream shop at the beach. And if you can't make money at your ice cream shop at the beach, it's not the heavy hand of regulation. That's the problem. It's the business model. The hospital before us today has a business model that continues to focus on expansion, adding administrative layers to build for a savings future when the savings have never materialized. And then raising prices on a shrinking population of patients with commercial payment. The prices have become unaffordable. This forces patients to forego care.  They still have accidents and need care. And then end up with bills. They cannot pay. They go into debt to pay that some percentage of that end up declaring bankruptcy. When that happens, those bills remain unpaid to the hospital. So a focus on maintaining a hospital sustainability by raising commercial prices is short sighting. Unpaid bills will lead to an unsustainable situation. Unaffordable care threatens sustainability. With that, I'd like to turn it back over to chair Foster. Thank you. Thank you. Number Welsh. Number homes. Do you have any comments or questions for staff? I do have a quick question for staff on slide 19. Could you just pull that back up? Great. I just wanted to make sure we understood that that 91.48 is $91 million of potential opportunity over the median. Is that how we interpret that? Okay. Yeah, so that's for that subset and it should be millions should be on that graph. My apologies. It's totaling that subset of items that was over the median that I showed previously allocated to the hospitals based on their NPR, which is how they reported they perform that shared services allocation. Yeah. Thank you. Just wanted to clarify the level there. Okay. Thank you. Appreciate it. So in terms of, I mean, this is this is hard, right? We are all in a very difficult position and I respect that the networks are in a different difficult position. We've gotten a lots of public comments on all sides of this issue. Just to frame where I'm sitting as I look at this potential motion language here. I viewed last year's budget as a recovery budget. So the approved rate increase of 14.8% last year was higher than almost all other hospitals and well above inflation last year. It was designed to be a one time bump to shore up the academic medical centers finances and it was a really tough rate to approve last year. I knew that that high rate would contribute to high premiums and potentially compromise access for those patients who delay care or avoid care because of cost. So it's a really hard position to be in last year and here we are again. Fortunately, the higher rate last year did shore up UVM's position. So as as the staff showed the hospital has seen higher than expected revenue higher than expected margins this year particularly since January when that commercial rate increase kicked in. And I just want to say this is despite very public cries of woe by the network when the board didn't approve their full rate request last year. So this year's request of 13.5 is again high much higher than inflation. And in my opinion, a two year rate increase of close to 30% was not supported in this year's submission. The record actually shows that year over year double digit commercial rate increases are not the only path that this hospital can use to generate financial stability. There's potential for on budget revenue and the tens of millions of dollars from increasing their case mix index a process that's already underway. There's higher than budgeted reimbursements coming from New York Medicaid that will ask also add on planned revenue and fiscal year 24. There's tens of millions of dollars of higher than expected investment gains that are another potential revenue source that could be realized if need be. And again, the higher than expected operating margins for fiscal year 23 or another resource to be tapped. Finally, I just want to say that there is nothing in the record to validate that the outpatient clinics are maximizing productivity and optimizing patient throughput. During the hearing evm's leadership, I confidently said that they would share productivity measures and industry benchmarks, but we never saw that data. And all we have is the visit per clinical FTE data and we have known wait times and that clinical visit per clinical FTE suggest is looked low to me. Again, we didn't see other productivity measures or industry benchmarks, but we know that there are very long wait times. And so there's potential opportunity to generate additional outpatient revenue by increasing patient throughput. So on the revenue side, in my mind, there's ample evidence in the record that a double digit commercial rate increase is not the only avenue to cover expense growth. And then when we look at that expense growth, there is some evidence presented by staff that suggests that there are opportunities to reduce costs that would further reduce the need for such a high commercial rate increase. A reduction in admin expenses could help UVM maintain a margin with a lower commercial rate increase without even talking about service cuts. And there was really not a lot of evidence presented of significant efforts to really look at expense growth and reduce it. A casual observation suggests that UVM, you know, I'm guessing this from the narratives and their description of how they build their budgets, but it appears that the network builds its budgets using an incremental budgeting approach. In other words, this year's budget forms the basis for next year's budget with adjustments upward for inflation or changing demographics or public payer reimbursements. But the assumption in that approach is that the budget foundation is sound and incremental changes are the only ones that need to be made. And if that's the budgeting approach, then cost and efficiencies are going to be baked in and compounded year after year. An alternative approach is zero-based budgeting, which starts with a budget of zero and requires justification for every single line item. It's much more time consuming. It's resource intense, but a zero-based budgeting approach every few years can uncover significant cost savings. So I would love to see if they're not doing it already, a zero-based budgeting approach for next year. Anyway, given the opportunities I think that I see that staff have presented and have been, you know, presented in the record, I think there are opportunities for revenue to be generated from sources other than commercial rate. I think there's potential for administrative cost savings. And so I don't think that the Medical Center met its burden to justify this year's commercial rate ask. So I do support the staff recommendation, which would still allow for a two-year rate increase of almost 18%, which far exceeds inflation. I think some others have wanted perhaps a larger cut or a cut in general, but I think that a glide path with an inflationary increase would be less disruptive. So I support the staff's recommendation on charge increase. I also support approving the requested NPR in the hopes that UVM can increase productivity, increase patient throughput, and generate additional revenue by reducing wait times and providing the backlog of care that Vermonters need. So I am in support of the staff recommendation. Back to you, Chair Foster. Thank you, Member Holmes. I just observed that this was a very large budget proposal calling for a 28% increase in commercial rates in two years, which is multiple medical inflation at a time when Vermonters are struggling under the weight of extremely large commercial rate increases. I note that UVM's own executives for years have publicly acknowledged that healthcare costs are too high. They're not just too high now, they're too high before. Yet UVM has perpetually demanded rate increases that far outpace inflation and what peer institutions appear to receive. I re-read our statute and I noted that the legislature has stated that overall healthcare costs need to be contained and that, quote, growth in healthcare spending in Vermont must balance the healthcare needs of the population with the ability to pay for it, close quote. To me, this budget request was anything but that. We heard in connection with Baz's request to modify the 8.6% guidance that the large rate increases were harming Vermonters' ability to afford care and that people avoid and delay care when it gets too expensive. We also had robust public comment from community providers that they've been receiving small rate increases and they were unable to bear the cost of inflation rising nursing salaries and face many of the same financial challenges that hospitals had. And unfortunately, we have seen in our community, community providers close or limit access, which is bad for our system as they too provide critical services often in an economically efficient way. Having said that, I view this hospital as a cornerstone of our healthcare system. It's immensely important to our state and to the community. And it is filled with excellent providers, many of whom are friends of all of ours, who build very extremely high quality critical services. And they do have financial challenges that need our support if we're going to maintain the access and quality of care that we need. So while I can certainly understand that a lower rate increase would be appropriate based on the record that's before us, and I struggle to justify to Vermonters why another large increase on top of last year is warranted, I think that we have to do it. I think that we need to provide this hospital an increase that keeps up with inflation, so that it's time to address and rectify its inefficiencies and high administrative costs. I'd also note that they have new leadership, and it may take time for Dr. Eppen to surround himself with all the pieces and team and structure that he believes is appropriate and to create a culture that is in his vision to address the challenges the hospital has. So in light of those facts, I think that providing an inflationary increase is warranted. I have a couple other notes that struck me from the process. I did not find evidence to support many of UVM's assertions and others I did not find credible. For instance, the testimony and evidence relating to CMI was not consistent with some of the information we received in public comment. At the hearing, the board, the guy asked UVM for its assessment and benchmarking, and we were told we'd receive it, but then UVM did not provide it and claim confidentiality. But we often review confidential information and it's difficult to evaluate and find the claims credible if we don't have the data and information that backs it up. We had the same issue that Member Holmes discussed with the productivity data. The board asked about provider productivity and what benchmarks were being used and to measure provider productivity, but that information wasn't furnished either. And when we get incomplete answers or just non-answers, the credibility of those assertions is eroded. I also was reflective of the 2023 budget process. UVM's request last year seemed to be inaccurate, which is okay. We understand that these are very hard, but UVM indicated a 19.9% rate was necessary and the board didn't approve it. There would be a parade of horribles. UVM in fact testified last year that quote, it really isn't until 2026 where that operating margin is back into the three plus range where we need to be heading. But partially through 2023, UVM is already north of a 2% margin and that slide eight director Lindbergh showed the trend and the trend is decidedly upwards. So after the board reduced the rate by 5% down to 14%, the margin is still far above what UVM had testified, but it would be at 19%. There's also a claim in last year's transcript in the testimony that quote, that UVM was quote, underfunded continually by our regulators, close quote. I don't think that medical centers continually underfunded. Its prices are high, its rate increases are well above medical inflation and more than peers. Its revenue was $226 million above two-year inflation. Lastly, I'm not sure exactly who it was, but a couple of members mentioned the efficiencies and network costs. And the issue of consolidation and increased cost has been discussed for years here in Vermont relating to the network. And UVM has consistently maintained that its expansion will behoove Vermonters by resulting in lower cost to consumers, economies of scale. In 2015, UVM CEOs stated that efficiencies in the network will create and eventually reduce cost to consumers. In 2017, member Holmes asked during a hearing that one of the things she was hoping to see was the benefits of affiliation and should these economies of scale lead to lower operating expenses. Holmes noted that that's not what was seen at that time, that they actually saw some of the highest growth and expenses back in 2017 and asked quote, when and where and how are we going to start to see the efficiencies. UVM CFO is quoted as saying that every entity right now is an island to itself from a technological perspective with different billers trained in different operating systems. I'm not going to need all the same billers once they're on Epic and that putting the infrastructure in place will deliver the efficiencies. Automation is the administrative areas in the administrative areas is really the driver of efficiency. In 2019, the chair of UVM health network Ali Stigney and Steve Lefler submitted not bad to VT digger with the question of whether or not the formation of the health network would cause prices to go up. That conclusion was quote. The answer is the resounding no close quote. It's now years later, and these investments in hopes of efficiencies have been expensive and for monitors have paid for those. We'd hope to see those efficiencies by now and that they'd show up in cost containment and containment of expense growth and more efficient and increased productivity sort of wait times and lower administrative costs. But the forest does not show that UVM's answer to this question were at best anecdotal and incomplete and did not address the questions about changes in price pre and post consolidation. The administrative costs at each of the hospital networks appears quite high quarters at 29.25% CVMC over 30% and UVM nearing 25%. That's by UVM's calculation, not off of the cost report data that the care board analyzed. The claims was concerned in 2017 because expense reduction wasn't showing and today, six years later, I have a hard time seeing that's pulling through. And I say that because it gives me optimism that if the claims of efficiency are true, there remain significant opportunity to lower costs that has yet to be tapped. I am concerned about a 24% MPR growth, but for the same rationale as the other members, I think allowing UVM to maintain that very high MPR growth is beneficial in this circumstance. What is not beneficial balancing all of our statutory obligations is a very large and unwarranted increase in commercial rate. Lastly, I would note that the claims and concerns about cutting services, in my view, wasn't really supported. It did not look like there was much evidence provided. It seemed very thin and it does not address all the other opportunities to find efficiencies and cost savings and other revenue opportunities. So that did not give me concern. I think that UVM has plenty of ability to cut any rate reduction by increasing productivity, essentially tapping 50 plus million dollars of unexpected investment gains, finding economic efficiencies in the administrative state, and also through the CMI project that it spoke about. So if you look at the factors we're directed to consider, including for modernizability to pay for the care, the efficient and economic operation of the hospital, the healthcare system needing to maintain system costs and eliminating unnecessary expenditures, including by reducing administrative costs, reducing costs that do not contribute to efficient, high quality health services. I am supportive of the budget's proposal from the staff. I will open it up to public comment. The motion is appears. We can take public comment and then we can see if anyone wants to take up the motion. Ms. Gutlin, please go ahead. Ms. Gutlin. Yeah, okay. Can you hear me? Yes, ma'am. Okay. So I'm sharing Gutlin owner of a major provider of outpatient physical therapy. I'm hoping to not be thought of speaking up against motherhood and apple pie here. I'm a mother and I do love apple pie and I do appreciate the UVM Medical Center. But I wish the hospital could understand it's not me speaking against UVM, but rather for the healthcare system as a whole, which they are only a part. And it's this bigger picture that Vermonters face. In my professional lifetimes since graduating from UVM in 79, that's 1979. This business has gone from being a single hospital in two parts to being a bohemian entity which has been allowed to expand far beyond being a hospital and to dominating all of Vermont healthcare. Profits have fueled this expansion and its expansion has fueled more privileged status and protection of this power. Access is a big deal, but depending on the most expensive hospital owned care to increase access goes against affordability. Affordability is existing right now, but shrinking in the non regulated part of the healthcare system. I certainly believe good people are running this hospital, but their perspective is from the inside as if in a bubble, not willing to acknowledge its effects on the totality of the healthcare system. Like they're the only thing. And they must be paid more because if they're not paid more than the whole system will crumble. This lack of awareness was witnessed in a dumbfounded response when questioned if they knew how their budget demands affect other others in healthcare.  Testimony from Blue Cross Blue Shield confirmed that increases going to the hospital means near flat increases for the private sector. In my part of the private sector, while inflation has been over 35, 36, 38% in a period of time. I have received 8%. Anyone that understands math and understands inflation cannot understand how it's possible that a business could even be in business. So I have had to cut costs, I have had to cut services. And I expect every part of the healthcare system to do the same. Being unregulated I do not think to have my financial picture considered by the state in efforts of sustainability. I have this, I have public comment. And the public frankly isn't even plugged in. They read, they read, they read opinions and papers of how important the hospital is and how much the public should support them. This one sided hospital focused support has created disparities and payments that are in some cases in my loan sector over 500%. Looking at this from a patient's perspective in physical therapy where they would be subject to an expense a bit over $100 a visit coming to my business. They face a bill hundreds of dollars more per session and thousands over the course of care. Patients are not told of this. And it's assumed well insurance will cover it, but they're out of pocket expenses are, are, are gone up in, in some of these people are paying 100% of these thousands of dollars more out of pocket. And the providers at the UVM Medical Center are not collaborative. They don't, they don't provide encouragement of patients to think about their options where finances are a consideration. In fact, we're repeatedly told by patients they were never given a choice. This hospital's growth is not providing for health to our Vermont population. We don't see Vermonters healthier. And it's certainly not helping their financial health. The sustainability of this healthcare system, not just a piece of it depends on preventative care and we hear this over and over again. But a business that profits on sick and injured cannot be expected to keep people out of their business by being healthy. But that's the image they project, right? We're going to drop, we're going to drop services and primary care or, or, or, or mental health. But it's already being provided by the private sector at a more affordable rate. So I urge UVM to stop being the king of the mountain and having an attitude of superiority and collaborate instead of compete with the private sector. Instead of trying to be the end all of all of healthcare. Look at what's already available in the community, encourage your patients to take advantage of these options to get and stay fit and healthy. In the 20 years I've been in business, not one person from the medical center has ever looked into what the rehab gym does. We're the only medically oriented gym improving the health of Vermonters. If this board, if the trustees of the hospital, if employees of the hospital really truly care about the health of Vermonters, they would want to know what's going on. I urge trustees of this hospital to educate themselves, ask the walls of one entity and dive into the potential of population health improvements. If only UVM would think about divesting from services unrelated to the care of the serious ill and injured. That's what hospitals were designed to do. That's what they did. And when they entered this monopolization of healthcare across our nation, there has been no improvements. When are we going to learn. So trustees care about more than the financial picture of this business and get into the health of Vermonters. And I urge insurers to stop payments based on market power and instead on what's best for their members. You're the boss to the members, not the boss. No, your members are the boss of you, not a hospital. They should not control your decisions. And I urge patients, if any are learning and we all are, is to learn about options and shop around. Thanks. Thank you for your comment, Ms. Goodwin. Mr. Vincent, I think your hand was up next. Thank you for the presentation today. I just have a few comments to make based on the discussion and the data that was presented in the slide. So one, I do want to applaud the staff for the movement they've made this year in presenting more data and having data be a key part of the deliberations. But there's definitely work to be done in terms of refining that data and that benchmark those benchmark sources. I think we provided some very clear evidence on one key piece of the of the data that's being used this morning on the administrative salaries, technical salaries data that had. And again, we didn't have as much time to dig into this either, but we did have time to dig into a few of the hospitals that were part of the benchmark. And we clearly showed that if everybody used the proper columns on the cost report like we did when we calculated our 24% that you can see dramatic changes in what those results would be. We had to two community hospitals that in the benchmark data are listed at 5% administrative salaries to clinical salaries that would jump to 34%. Another one that would that would jump from 4 to 28%. And even made medical as an academic medical center and that database jumps from 13 to 48%. So that benchmark data that's being used is inaccurate. So in terms of how it's potentially being used today in the deliberations, I just want to highlight that again for the for the board. To in terms of the results this year for the medical center. Again, we tried to be clear with that in our response that there is one time money in that margin that you see today. That will not continue into into FY 24. So just want to highlight that again for the board. And then finally, my my last comment has to do with the focus on price when we talk about cost. Price is only one piece of the cost puzzle. The other piece is utilization. And when you look at it from a cost from a total cost of care perspective, these numbers that even that are still on the on the screen here the 23.8%. This number would look very, very different if this was if this was adjusted on a per capita basis and that is something that I hope we can move to as we continue to refine the the data that's used in these deliberations and that cost per capita also applies to the expense of an organization. It was there was highlights of the growth and expense from one year to the next. That is because the medical center is taking care of more people that cost component of the of the equation also has to be looked on a per capita basis and not just an absolute dollar number. So we actually are very much looking forward to the day that the that total cost of care and population based payments become the the predominant reimbursement mechanism because we're obviously very confident in how we'll operate in that system. Thank you. Thank you for your comment. Mr. Vincent. I think I'm pronouncing the name right. Drago Spano. Yes, you did. Thank you very much. I hope you can hear me. Okay. My name is Drago's. I'm a general internal medicine physician. I've delivered primary care almost entirely in rural communities. I used to practice upstate in New York for the last eight years at Dallas Hyde, one of the sister hospitals of our network and transition here starting my third year for the academic medical center. Currently provide care in Essex and I thank you all for for this. This was very enlightening to me as a new Vermonter and learning how my new state functions. But I wanted to give you just a glimpse from my eyes in my day to day delivering care. And I can tell you either that is in most rural communities like I used to serve upstate. I have seen so much goodness from this network from this network, which I have remained loyal. I have seen communities receive state of the art care such as enrolling in clinical studies where otherwise it would be impossible. Since my arrival here. And as I mentioned, I'm starting my third year. It is not all beautiful. We have a lot of work to do. And I agree with all of you. Access probably top of my priority as a physician. But I have seen I have seen in a very limited time. Hiring of new physicians of new advanced care providers. And this is really really feels good for many reasons, obvious reasons. I have seen a psychiatrist join our primary care practice as part of the new model of delivering care, which has been a game changer.  And as colleagues, as I'm sure you do with your own colleagues, we talk and we speak on challenges on personal issues and on on what we can do better and specifically from somebody that's new here, relatively. And same thing for the new staff we hire. It's challenging housing is challenging costs are challenging. So I am really encouraged to see from my eyes as a internal medicine doctor as a member of the state. And also as a loyal worker for the network that in my view, it's going in the right direction in a very limited amount of time. And I've only been here for two years. So take my comments with with the grain of salt. It's only from my view, but it feels good. Thank you. Thank you for your comment. In the state. The next hand is Mark. Thank you very much. My name is Mark. And I'm an emergency physician that works clinically at Porter hospital. Central hospital and University of Vermont. I'm also the quality chair for the network emergency departments. So I'm very involved in emergency care across the network. And I'm the associate chief quality officer. So I know today the board's going to make a choice and that choice is going to impact the care that reminders receive for years to come. The UVM health network EDs are really the safety net for a significant portion of Vermont. We are constantly doing more, more with less. We stabilize care for and discharge patients that had any other academic medical center in England would be admitted to the hospital. I've worked in multiple different new England states in the 17 years since I finished residency and I can tell you without a doubt we're more efficient and work harder than do more with less than any other academic medical center work. In addition, UVM is really only this is the only safety net for Vermonters who need tertiary care. This is very different from other areas in England where there's multiple tertiary care hospitals in a short and then in a short radius or small areas. I see it was really the only tertiary care I see you around and we're the only one who can help for monitors when they're in their worst moments. One of the roles I serve by work as a network physician coordinator and I take calls at all hours of the day and night on weekends and on holidays collaborating with emergency physicians across the state. We need to transfer their patients to the end. Many times the physicians I'm talking to are working at hospitals that are closer to Dartmouth or Bay State or Albany, but those hospitals are refusing to take the patients back even though they're critically sick. And oftentimes they're having a complication from care that they received at those hospitals. Unlike in other states where these patients could be shuttled around to multiple different places, UVM becomes their only choice and therefore we have to make capacity to take those patients. When Vermonters need this medical care, they don't need budget cuts and long waits and overburden nurses and providers with less access to care. They need higher caliber facilities that are modern and have all the infrastructure we need. They need well trained physicians, nurses and staff. We all agree, Vermont is an access to care problem. Everyone on the call acknowledges that today. This pressure though really translates the emergency departments across the network and across the state. These patients show up when they're when they're finally decompensating to the point where they really need help. Emergently and when they come in, they don't tell us we couldn't afford to pay for care and that was why we didn't go. They tell us we couldn't get care due to long waits. And this is even for patients who are accessing non-UVM health network services. This is not just patients who are trying to get into UVM clinics. The emergency departments are constantly working with limited resources to stabilize these patients and then coordinating their transfer to UVM. The hospitals in Vermont are constantly absorbing sicker and sicker patients because we don't have capacity for them in UVM. So we need to get, we need a day or two to kind of open up capacity and bring them in. Some of these patients are dying while waiting. We've seen those cases increase with frequency. The only way that Vermont is not for profit hospitals are going to work well to serve all Vermonters is if we can continue to grow the health network so that we could expand our services and be able to better assist not only just the partner hospitals in the network, but all the Vermont hospitals, including the eight critical access hospitals. I think our mission is the health network and the mission of the board are exactly the same. We want to provide the best care for all Vermonters. These are our neighbors, our friends or relatives. The doctors who are working in the system that are all under unbearable stress are also neighbors, friends and relatives. I can tell you for sure that we all come to work early. We all stay late. That we all take on additional work to improve quality and operations in our free time. We're not, we're not operating any efficient. We're, the network is not for profit and we're really looking to stabilize finances and ensure that we can continue to provide really good care to all Vermonters. I think there's only really one choice here and that's that we have to look at this comprehensively and look at the stream the system is under work and sit in the budget. I hope we can work together and take, continue taking care for all the months. Thanks for allowing me to comment. Thank you very much for your comment, Mr. Pazonzo. The next hand is Louis first, Mr. first or Dr. Yes, how are you? How are you? Thank you, chair Foster. Good afternoon. Good morning. And I want to just thank the board for allowing us to sit in and hear your discussion. My name is Louis first and for the past 29 years, I have been chair of the department of pediatrics at the University of Vermont Larner College of Medicine and chief of pediatrics of our UBM Children's Hospital located at the medical center campus in Burlington, the UBM medical center campus. Currently, my tenure as pediatric chair is the longest in the country, and I am proud of that fact that I have served in this role as long as I have. Not because I want to call the Guinness Book of World Records, but because of how fortunate I believe our state is to have the pediatric physicians, nurses and staff that have been recruited over the past several decades to provide state of the state of the art high quality, cost effective, family centered pediatric care and preventive health strategies to the children in Vermont and upstate New York. The pandemic being a great example. Our ability to surpass national standards in the care of children with disorders like cystic fibrosis and inflammatory bowel disease, pediatric cancer is not something any of us should really take for granted. Our mission has always been to get it right here in Vermont and upstate New York and then share our innovations and care systems with the rest of the country in the world, which is what we are all about. Yet with each passing year that I've been here, I have begun to worry that there is a sense of complacency of our being taken for granted that we of course at our Children's Hospital do whatever it takes to provide whatever children need in the state for their healthcare needs. And that is just not feasible. We see every child that needs to be seen. We are tucking children in left and right in our specialty center. But basically, you know, revenues are not the salvation in pediatrics without the ability to have sufficient funds available to not just grow our programs but simply maintain them. I worry that we will have to cut back essential programs that we've been able to offer for years with high performance outcomes, lower costs because of our inability to have the capital funding. Let alone the programmatic funding to retain the remarkable people that make our Children's Hospital the go to place when our children, our grandchildren and our neighbors children need us already this past year. We have had to put a pause on new referrals to our adolescent programs and our autism assessment programs due to lack of space, staff and funds to meet the referrals we are receiving and we are trying to see these kids left and right. We have a neonatal intensive care unit that barely meets code and has been in need of new space for well over a decade now, if not longer. So if this motion passes, it would seem appropriate at a time as you've all pointed out when health care costs can certainly and are concerning. But it could and certainly I might be going to worsen our ability to sustain the gains of pediatric care that require the capital funding and the staffing needed to hit that access point as the state's only Children's Hospital. The alternative of needing to send more of our pediatric patients out of state if we can't upkeep our our space, retain the staff that I've been so proud of for the past three decades. We must provide is not is not an option that any of us want to see for the Children and Families of Vermont. I hope that you do factor in the future of Children's Health and our Children's Hospital when you vote on this motion. I want to thank you for your consideration and I do hope not in budget season, but during this year that I have the opportunity to come back and update you all on how high quality and how cost effective. Our UVM Children's Hospital has been and I hope will continue to be as we look to the future. Thank you all very, very much for having the opportunity to share my thoughts. Thank you very much, Dr. first for taking the time to attend the hearing and to share your thoughts. Next. Deb snow miss now. Hello. Again, thank you for all the hard work and especially to Sarah Lindberg and Elena Barube for all the work they put in, especially with the suggested motion language. I do want to start off by saying that I totally appreciate the language in here. I do hope that we continue to hold not only UVMC, but the network accountable for reducing costs at the network level to reduce the top heavy management level and to really put money into recruiting primary care physicians and APR ends because that is what is needed at our state level as well. I do hope that when we talk about benchmarking and market values that whatever benchmark we are using, we start using consistently and use it across all levels of employees at the hospital. And lastly, I just want to acknowledge that the UVM Health Network Board recently sent a letter to legislators. I personally as an employee at the hospital. I'm not going to lie. I was embarrassed at the tactics that our network level was using against the Green Mountain Care Board. I don't think it was appreciated by the general public and it's it I hope that the network learns from this whole year's budget process. That's Vermonters come first, the patients come first, and we need to keep the patients before profits going. Thank you. Thank you for your comments, Miss Nell. Next, Sarah Palowski. Hello everyone. Thank you for the opportunity to talk. My name is Sarah Palowski. I'm a child, adolescent and adult psychiatrist and I trained in Vermont as a resident in psychiatry and completed my fellowship in child psychiatry here too. I have worked across many settings and the mental health care system across emergency room inpatient outpatient and community mental health among others. I serve as a clinical leader of primary care mental health integration with a focus on improving access to mental health care in primary care for all people of any age and any insurance at the UVM Health Network. I was proud to present this work to you last year with my colleagues as one of the many hope for solutions for a mental health care crisis and lack of mental health care access. I am here today because mental health care is disproportionately impacted by budget cuts and I see the future of mental health care funding at a concerning impasse at a time when we all can agree we are in a mental health crisis and need more, not less mental health care. As a board, you have pledged to improve our mental health care system. I am here because such endorsements require funding and programs such as the one I have presented to you become vulnerable with budget cuts. Medicare, Medicaid and private insurances simply do not reimburse enough to make private practice psychiatry sustainable at scale, which is a main driver of lack of access to mental health care. Therefore, every day I see patients and families who rely on mental health care delivered through the primary care medical home because it is the only outpatient mental health care accessible to them. The only way we are able to accomplish this is through resources paid for by the UVM Health Network. As a service that is limited in revenue generation, but is nevertheless demonstrated itself to be invaluable to the community, budget cuts will affect us very directly and very dramatically.  This is the hour-to-hour story of my job. I hear again and again that without our team they may be on a wait list for a year and they can't stand to watch their child suffer that long as any parent can attest to. I have also been the parent with the child on a wait list and I can appreciate the agony of that as I'm sure you can. If you have ever loved someone whom for whatever reason could not get the care they needed at the moment you felt they needed it most. Funding for mental health care is essential. Many of you agree publicly and I appreciate as a provider of that care your kind words of support. And while your words are of support, any choices which defund mental health care would be anything but supportive to us and the Vermonters we care for. Programs like ours are not financially sustainable through traditional health care payment mechanisms. We are costly with people power and need more time during each visit than a procedural visit all while reimbursing less. Programs like ours rely on sharing financial resources usually taken in by more lucrative departments. Budget cuts will drastically and directly limit our ability to care for our fellow Vermonters and limit expansion of our services to communities in need across the state. When you make decisions about budgets, I hope you think of the mothers who agonize when mental health care is made further inaccessible and more programs such as ours of which you are so supportive about last year are forced to end and more emergency room mental health care results. I'll finish by saying thank you for listening. Thank you for your words of mental health care support publicly and I do hope that in making choices you can reconcile those words with the matching decisions. Thank you very much. Next hand is David Schneider. Mr. Schneider, please go ahead. Hi there. My name is David Schneider. I'm the chief of cardiology at the University Medical Center and I'd like to also focus on the clinical aspect of this. I'm very proud to say we deliver outstanding cardiac care to the patients of our state and the Medical Center is essential to care for patients both with chronic and acute conditions. The pandemic really had a damaging impact throughout the country on health care and there are many health care workers who left health care during that time. And unfortunately, we still have not stabilized the system and because of that we're short on personnel and we have to use travelers which drive higher expense. I'm proud of my institution that we use those travelers so that we can actually provide the care that patients need when someone has a heart attack. They literally have their life threatened and if they can't get access to our institution they will suffer either the consequences of potential death or greater morbidity associated with the heart attack. We struggle today with getting patients in in a timely manner. I'm worried that budget cuts will actually further have further implications and really reduce our ability to provide that life saving care. It's important to note that having been in this state for more than 20 years, I'm excited to say that I actually take care of some patients who I met during my first years in this state and at this institution who came in with a heart attack and who now continue a very active and vibrant life because they received acute care in a timely manner and then appropriate subsequent care to really prevent second events. Throughout my entire career here, it's really been about providing appropriate acute care and really working to prevent both primary events and secondary events. I'm proud of my time here. I'm very concerned that reducing the budget as proposed could have negative implications and our ability to carry out this essential mission. We are the only cath lab in the state that's very appropriate, but we actually need to support that service so that we can provide this very important care to the patients in our region. Thank you for allowing me to speak. Thank you, Dr. Snyder. Ham Davis, please go ahead. Thank you, Mr. Chairman. I've been really critical of this process of the board's process over the last several months. And given that, I would just comment that I think that the, at the end of the day, when you look at that, that the, that the board has very done very well in taking care of, it's really its very first responsibility, which is to maintain the, the ability of the academic medical center to function. That was not a given. That was certainly not necessarily expected in the light of the what has what had the board has talked about over the last several months and especially recently. So I think that is, that is excellent. And I mean, the fact of the matter is that that that looks to me like UBM can handle this without, without much trouble. The further comment would be that I continue to think that the, that the board is not really grappling with the second real is the most responsible, the biggest problem that they have, which is getting the rest of the hospitals. Within some kind of a reasonable system, we have, we have 14 hospitals for 600, 625,000 people. That's way more than we need. And the, and, and, and I think that Rick Vincent is completely right that if you, if you shifted to a cost per capita, which is the way we actually pay for health care, that UBM would look better. But the challenge now it seems to me is for the board to consider really start considering the underlying issues of the sustainability project that started with member homes back in 2019. And that would be, that would involve looking at the massive data that describes the, but not only the cost efficiency and quality, high, very high quality of UBM compared to the rest of the UBM hospitals, but looks at very important issues in that small hospital network. That will be much harder. And, and I wish you good luck with that. Thank you. Thank you. Thank you for your comment. Mr. Davis. We, we are a number of people probably recognize we will be engaging in the act 167 work really soon. I think it's actually beginning now. And Mr. Davis, I've heard you comment on this a couple of times. I would love your participation in that. I will put you in contact with our consultant because I've heard you on this and I think you're right. There's a lot of really important work to be done and that realm at work should be starting, I think, this month, next month, December. And I personally view it as really, really important work. The next person is hand raised is Katie. Katie, if you could just. Yes, I'm Katie Ares and I'm one of the doctors and owners of matri health care in South Burlington. And I just wanted to make a couple of comments. One is that we, I obviously completely agree that UBM medical center is essential to providing care for our patients in our community. I mean, we do all of our deliveries at UBM medical center. So we would not be able to take care of the women in the community that we take care of if UBM were not to continue to function and provide excellent care for the women that we need to refer to them. But my biggest concern, I feel that a lot of this has been talking about how we will be losing access to patient care if the budget doesn't continue to continue to increase for UBM over time. But I think it's really important to recognize what that does do to do to the rest of the community providers and that our budgets do not increase substantially year after year, despite the insane amount of increase in cost we have from inflation, as well as competing with UBM's ability to pay their nurses and their medical assistants and their support staff more than we can afford to pay some of our staff. So I think as the only other provider in the community that provides obstetric care to women in the community, we do about 780 deliveries a year. UBM could not absorb 780 women to take care of and deliver annually if we were to shut our doors. And I think the sustainability of increasing the budget every year at substantial rates that don't only impact the Vermonters cost of healthcare, but also impact what we have to pay for our employees to get healthcare and for ourselves to get healthcare. It really impacts the sustainability of the private practices in this community who provide a very, very important service to these patients. I obviously feel very passionate about women's healthcare and we work very hard to get as many patients and women seen in a timely manner as we can. We see patients over lunch to avoid them going to the emergency room and after hours as well. So I think that I don't disagree that we need to keep UBM working. We need them and I agree that there are specialists there that are extremely important for us. So I'm not saying that I don't believe in continuing to support the hospital, but I think it's really critical to think about the impact of the hospital's budget and how it has an impact on the community providers and essentially eventually access to care throughout our state and our community. Thank you for listening. Thank you, Dr. Susan. Hi, thank you for the record. I'm Susan Ridson of Vermont Health First for independent practice association representing 62 physician-owned practices in Vermont. I just want to thank the board and staff and everyone involved in this process for this hard work. We definitely support the board's attention to healthcare access and affordability in these hearings. We also appreciate the board's consideration of the downstream negative effects that multiple years of increases in commercial insurance rates and hospital budgets have had on high value community providers such as Dr. Harrison at Maitree. And then the rest of the healthcare system and just everyday Vermonters. As Chair Foster, you stated and others have stated community providers have had to face many of the same headwinds of the hospitals, but because they have little to no negotiating power with public and private payers, they're unable to increase their already comparatively much lower reimbursement rates to cover the ever increasing costs. As a result, these independent practitioners must cut their costs to the bone, optimize efficiencies just to survive. It's imperative that all players in our healthcare system similarly reign in their spending and find efficiencies such as the ones that your staff and board members have pointed out are available. Vermonters just simply can't afford for our system to do anything but that. Thank you. Thank you. Next, I'll turn to Roger. Roger, your hand is coming up and down. Hi, sorry. Yep, I do. I had kind of three thoughts on this. The first is that, I mean, I, I guess to take a step back, we all support the hospital. I mean, I was born at the hospital, my kids are born at the hospital.  I don't think anyone is suggesting that's not, that's not the case. And so this, the idea that anyone is advocating for something that's not kind of continued quality care at the hospital I think is just is just incorrect and misguided honestly. I think it's really important to take a step back from a financial perspective and say, you know, we can get lost in the sort of month to month or annual metrics of, of whether it's performance or cost increase, or that kind of thing but I mean, when you step back from a sort of Vermonters perspective, health, the cost that we are paying for health care is, is out of control and it's honestly out of control come here to other states to other developed countries it's it's it's and when I say out of control it is, I mean I was on the select board in the town of Richmond, and all any, any benefit increases that we are trying to give to employees that the employees are expecting is all going into health care. So I think it's, it's really important to honestly take a step back and just say, what is this overall where are we with the overall rate of inquiry. And, and I think the idea that how do we control that. Is there a way to control it without cutting services. That seems obvious. Well then let's figure out how to do that. But this, I mean I guess I would have to call it a threat that while we're going to have to cut services. What I would remind the board is that public health is about making choices to find the sort of relative goodness to society if that makes sense. Public health is about making decisions that hurt some people and help others, because ultimately this is a zero decision to a certain extent. Right so decisions are going to hurt some people and help other people and we're trying to maximize the public good. And people are limiting care, there are real health impacts to the increase in costs that we have had in this state in the last 15 years. And that's just a fact. That's just a fact that the cost increases are limiting access to care from Bermaners. And so are there are there services that we need to cut to sort of get that back under control. Maybe let's let's look at them. Let's talk about that. Are there services that people could go to Boston. Maybe we can pay people to go to Boston. Are there kind of regional regional places to get care that that we don't need to do up here but I think just the threat of oh well we're going to have to cut services we are cutting service. That is what is happening now. And honestly the final thing I'll throw out there in terms of this regulation is this this sort of monopoly of health care is something that that the network has wanted. So the aggressive expansion is something that the network has really worked for and has been a goal. And I don't I don't understand how you could regulate how you can have any kind of a limit from a cost perspective that isn't regulatory. What's the what's the other limit. Right. They don't we don't want competition. We've really fought. I mean the I think the surgery center is a good example of something where the network UVM network fought competition. And so then what's what's the other mechanism for limiting that cost growth. And it's it's the board. I mean that's it. Now that's all we're left with patients don't have choice. We have wait times that are and it's the board. So thank you for hearing my my comment. I'm sorry about the uncertainty at the beginning. No problem. Thank you for participating in your comment. Let's go and raise our hand again. I'm going to go to her and then I'll give the health care advocate the final word and I'll be brief. I just wanted the board to be aware that Dr. Lewis failed to mention the pediatric care of disabled children. I launched the kids rehab gym from the pleas of doctors and parents asking me to fill the unmet need. And I reached out to him when establishing this care but never received a response. I no longer run the business. Now turned into a nonprofit just to be able to survive. I just bring this up as an example of UVM's lack of collaboration or even interest with community providers outside itself. And I do encourage Dr. Lewis to get a hold of kids rehab gym. Take a visit. I would think that you are a great pediatrician and I would think this would fit within your interest. Thanks. Thank you. Mark Hage. Thank you Chair Foster. For the record my Mark Hage the director of benefit programs at Vermont NEA and my union and Vermont State Employees Association jointly weighed in on this process in late August. And I want to just reiterate the points that we made in that letter. And also while the 3.1 percent charge recommendation here the increase is probably lower than many would have expected it is still in my estimation too high. And I think it could be lower and should be lower. I've been doing this work in health care now for my union and at the local level as a former teacher for more than 20 years. And I have been told repeatedly over that time that we're going to see lower costs and we're going to see improved access and we're going to see better quality. And frankly it just hasn't materialized. And I'm the person here at the office who takes the calls from members and their families who cannot afford their health care. And that's suffering and that deprivation and I know you know this but I'm compelled to say it. That suffering and deprivation is real and it's worsening every year. A month ago I stood in line at a pharmacy to fill a prescription and I listened to a gentleman plead to take his medication from the woman behind the counter so he could go home but he couldn't leave because he couldn't afford the $400 out of pocket. That story plays out in multiple capacities every single day here in Vermont and across the country. So I deeply appreciate your work. I know how hard it is. And as others have already noted this is not. Those of us taking issue with UVM HN this is not we don't think the hospital is essential or we don't value hospital care. These costs are too high and they are hurting an awful lot of people. I want to finally say on a personal note I found the recent written attack on this board by the network to be appalling and shameful. And those who wrote it should issue an apology. And frankly they should consider stepping down from their position. Thank you. Thank you for your comment. Mr. Hage. I'll turn to the health care advocate Mr. Fisher. Thank you Mr. Chair. Yes my name is Mike Fisher and I am the health care advocate. It's important to say to appreciate the process. This is a great deal of work has gone into getting us to where we are today from board staff from board members from the health network from UVM. And I really want to appreciate all of the public commenters from both within employed by UVM and and and the other ones. This has been a I think an important conversation with many great points that I would put my name behind. At the very beginning of this process the hospital association said hey if you know people who are not able to pay their bills send them to me. Now we thought about that seriously. And a number of people called me up and said hey why don't you take out an ad and tell people to call the hospital association if they can't pay their bills. We thought about it for a little bit and decided against it because that would be using people as a pawn. And my office works hard as too many people here to help people get the care they need. But it speaks to sort of a recognition of what's really going on in our community. And you know I think the piece of data that's that that we have is the last household survey that recognizes 44 percent of Vermonters who are commercially insured are are underinsured. Now what do you do if your exposure. Your out of pocket exposure is a high percentage of your income. How do you behave.  The way we experience people responding to that pressure is they wait. They hope it gets better. Now this is in my experience particularly acute in the world of mental health. When people have high exposure for the care that they need they they don't go get the care until it's most acute. And so I also I want to recognize that the the wait times issue and the and people waiting to get care because of affordability are not exclusive. They're compounding your weight. You hope it gets better. And then when you're feeling desperate you call and then you get in line for a long wait time. So I really wanted to make those points. And I wanted to appreciate the board for its work and I'm sorry I should have said this upfront. Like others have said we continue to be concerned about the amount of increase that is represented in this motion. 3.1% will we are concerned that it's too high and we're also concerned that the about the NPR increase as being unsustainable. Thank you. Mr. Chair. Thank you. Thank you, Mr. Fisher. And there's a lot of people on this. There's a lot of people at the hearing and I really appreciate the public participation. You can see we have a lot of different views and different voices. And that's what we're here to listen to as we try and make the best decisions we possibly can for monitors. I appreciate the discussion and thank you everyone so much for taking the time to weigh in on really critical decisions for our state. It's important. So thank you. I will move to approve the University of Vermont Medical Center's budget as modified here by with a 23.8% increase from fiscal year 2022 actual to fiscal year 2024 budgeted NPR. At PP a 3.1% charge increase from fiscal year 23 to 24 reduced from 10% and subject to the standard budget conditions as approved by board and an additional condition as follows. UVM MC shall submit to the board within three months plan addressing UVM MC efforts to reduce cost and control overall expense growth and connection with, among other things, information technology, human resources, management and revenue cycle management. Further UVM MC is required to meet monthly with board staff for monitoring purposes. A second. Is there any board discussion. I would just make one point myself, which I think based on the record before us. The monitoring makes sense here. We are concerned about UVM's ability to provide all the care that we need. And I think that the consideration relating to working with UVM to help control the expense growth is something the board should be doing. And I think we can do it collaboratively so that we are all working together to serve the community. Is there any other board discussion. I would on the condition. I don't think this needs to change the condition I would just say that that efforts and the planning should. Take into consideration any act 167 sustainability. Efforts so that we're not. So that all the efforts are rolling in the same direction. So again, I don't think that changes the condition. I just wanted to say that. Out loud. Great. Thank you. I agree. Okay. All those in favor of motion, please say aye. Aye. Aye. And the motion carries for the four votes. Dr. Merman abstained. It's almost noon and I want to make sure we give everyone a little break. Why don't we take 15 minutes and then we'll turn to the next two network hospitals at. 1210. That's okay with everyone. So we'll adjourn till 1210. Thank you. I'll reconvene our hearing of September 13, 2023. And we've brought Dr. David Merman back. We had a issue pop up for a care board member that they need to go and take care of. And this is going to cause a scheduling change today. And I know a lot of people made time to be here. I apologize, but someone needs to be elsewhere right now. And so we're going to just take up the standard conditions and then we'll turn to Porter and CBMC on Friday. Again, we're going to do the standard conditions and then we're going to do Porter and CBMC on Friday and I apologize for the unexpected change. So with that, I'll turn it over to Mr. McCracken. Thank you, Chair Foster. Sorry, Elena, should I share or are you sharing? I can probably present here. Hold on a second. Let me know if you can see the screen. Okay. So we're going back to here are the standard budget conditions. We've gone through this at a couple of prior meetings. There's one other sort of minor change that I'll flag for the board. And then if the board is ready, there's some suggested motion language here. As a kind of reminder, these are the baseline or default conditions that would get included with budget orders as the approvals indicate as the board goes through. They can as the board is done be modified or supplemented for a particular hospital based on on that hospital. So there are no changes to these conditions from what I previously presented to the board. There are some reporting conditions around here also no changes from what had previously been presented. There's an additional wait times condition that I presented at our last meeting, but there are no further changes around that. I have one change here in condition K. Which is I think really a drafting change to make it clear that. The requirement here is for hospitals to participate in the board's work pursuant to act 167. That includes the community engagement process. Substantively, I don't. It's not a change from what was intended previously. It's just making clear that that was the intention. And that was the only change. That we've made to the proposed standard conditions chair foster. At the last meeting had raised the possibility of including a condition around reporting how ACO primary care funds were. A particular ACO incentive funds were received used and accounted for and. We think that that's something we can address through the ACO process and review of the ACO's. Programs and payments. So we haven't suggested adding that as a condition for the hospital budget orders. So I'll pause there and take any board member questions or comments and there's some potential motion language on the slide here. Thank you. Any board member questions or comments or discussion. I'll say that I appreciate the team looking into my request and with their recommendation on the additional condition I had proposed and that I think is an appropriate recommendation. The only other question I had, Mr. McCracken is. There's motion language here. I forget if we receive public comment and healthcare advocate comment last time or if we need to do so in connection with this motion. Do you have a recollection. We have taken some public comment on the suggested conditions here before there's certainly no harm in taking public comment again. All right. Seeing nothing from the board, I will open up public comment relating to this motion. And to the conditions. Mr. Chair, Mike Fisher here. No further comment. Great. And I will ask if there is a board motion to be made. I'll move that we approve the standard budget conditions as presented to the board today to be included as the default conditions for the fiscal year. 24 hospital budget orders subject to any changes to the budget conditions or additional conditions approved by the board for any specific hospitals for avoidance of doubt. These are the standard budget conditions referenced in the previously approved fiscal year 24 hospital budget motions and approvals. Please second that. Any other board discussion. All those in favor of the motion, please say aye. Aye. Aye. Aye. Aye. And the motion is carries unanimously. Thank you very much. Mr. McCracken. I don't think we have anything else on the agenda that we can get to today. I think on Friday we are going to be a little pressed for time and so we'll have to try and be expeditious. And we'll work with our staff to see if there is any opportunity to extend time if need be or to address the change in schedule. So that is there a motion to adjourn? So moved. All those in favor, please say aye. Aye. Aye. Aye. The motion carries and thank you everyone for attending and for your participation today and have a good day. We are adjourned.


Hey, everyone. Sam here. Today, we'll learn how to handle online and offline states in your page the standard way. This will work with any framework or library. So let's go. Your device is going to be online with full access to the internet or offline. But there's actually a third state called Wi-Fi. This can happen when you're, say, connected to Wi-Fi, but there's no data flowing through that pipe, like this unplugged Wi-Fi router here. I'm on, I'm connected, but I'm getting nothing. So let's take a look at this. So I have this site I'm working on that fetches the weather for a location. Users leave it open and will refresh every few minutes. First thing, we'll check the property navigated.online. Yes, with an uppercase L. If this is false, we're definitely offline. So we'll show an error or some other message and probably the previous weather data. However, if this property is true, it doesn't mean we're online. We could be in this Wi-Fi state like I mentioned before. So we actually want to make a request for our data and see if it fails. If we get an error like a four or four or a 500, this is actually still a success. We can talk to the server and it gave us that response. But if we get an error or a promise rejection, this is actually a proper network error. We're actually offline and we can't find the other server. So now you know your state and your page can deal with it as if you're offline. We can show previous data. Now, best practice would be to retry the request later. You should automatically retry the request, but make sure you use exponential backoff. This means do a request after one minutes, two minutes, four minutes and so on, so you don't overload your server. And if your browser supports the background sync API, this is even easier as it handles the retry for you. Read more about that here. And also, listen for the browser's online event. This is fired when the online property changes back to true. Something has changed. Maybe you're still in Wi-Fi mode, but it's a great time to check again what state you're in. My best advice is that you should check for errors when making these kinds of network requests so that you can make a choice if you find out your users are offline. Your page can recover gracefully. This is really just one part of working well offline or with spotty network connections. If you'd like to learn more about serving your whole site offline, be sure to read up on service workers which act as an intermediate network proxy. So remember, check the navigator.online property, but don't trust it and install error handlers on your network requests. That's online and offline the standard way. See you on the next tip.