So it's one o'clock, so I'm gonna welcome everybody to the Green Mountain Care Board meeting. The first item on the agenda is the Executive Director's Report, Susan Barrett. Yes, and I saw that Secretary Smith just put his hand up to say he'll be right back. So I think if I go through my items, that will give him enough time. Oh, there he is, he's back. So he is right after me. So welcome everybody to our meeting today. I have a few announcements. First, for folks listening into today's meeting and for the public, we did have some additional items, presentations that were not on the website right before this meeting, we posted them. And we also made a couple of edits to existing presentations. So I'll urge folks to go on our GMCB website and make sure that you are following along with the most up-to-date presentation. Also as a reminder for presenters today, as you go through the slides, could you please announce which slide number you are on? That makes it much easier for those out in the virtual meeting to follow along with the presentation. And then last, I have a few scheduling announcements. First, next, well actually first tonight at 5 p.m. is our Primary Care Advisory Group meeting that is open to the public. And folks can find that call in information on our website, on our press release and on our meeting calendar. In addition, starting on Monday, we will be conducting hearings for QHP Rate Review, Qualified Health Plan Rate Review. On Monday, we're going to hear from Blue Shield starting at 8 a.m. On Tuesday, we'll hear from MVP starting at 8 a.m. And then Tuesday evening, starting at 4 30, we will conduct a virtual public forum on the rate review, the rate cases. So I urge folks to check out information on how to attend those meetings virtually online as well. And then last, related to the QHP rates, we are accepting public comment for those rates. They can be found access to how to submit public comments can be found in a couple of ways. First, on our website under the Rate Review section, you can submit your public comment there. Also under our public comment section, that will lead you to where you can submit public comments. And we are accepting those until July 23rd at 11.59. And that is all I have to announce. I'll turn it back to you, Mr. Chair. Oops, you're on mute, Kevin. Thank you, Susan. I'm gonna turn it back to you in a minute after the minutes, just so you can take attendance for the public record. Sure. So at this point, would someone like to make a motion on the minutes of Wednesday, July 8th? So moved. Second. It's been moved and seconded to approve the minutes of Wednesday, July 8th without any additions, deletions or corrections. Is there any discussion? Hearing none. All those in favor signify by saying aye. Aye. Any opposed? And just for board members, just a couple of housekeeping items, remember that the little hand on your toolbar, third one over from the right, fourth one over from the right. Click on that if you have a question for any of the presentations today and we will call on you. So with that, Susan, I'm gonna turn it back to you for attendance. Sure. I'm going to read off folks who are not from the Green Mountain Care Board staff and also for a phone number, I'm gonna list the last four digits of your phone number and if you could just announce yourself. So I see Spencer Wepler's on the call and then I'm gonna call out some numbers here starting with eight, eight, six, nine. Toby Howe, Emma Marr. Thank you. Zero, four, seven, six. Please put your hand through across the Vermont. Thank you. Seven, sorry, six, three, seven, six. Mort Wasserman. Hi, Mort. Eight, four, six, one. John Olson, Department of Health. Hi, John. Three, seven, one, one. Becky Lewandowski, DRM. Becky, seven, five, two, zero. It's Bob Hersey from NVRH. Welcome. Two, seven, nine, six. Two, seven, nine, six. Sorry, that's Carol Stone from Jiva. Hi. One, nine, seven, zero is our first, yep. Three, two, one, two. Three, two, one, two. Yes, hi. It's Kathy Mahoney from the General Advisory Committee. Hi. Thank you. Welcome. Eight, eight, eight, eight. Joe Wooden from Copley. Welcome. And then I see Abigail. I see Devin from Vaas. I see Howard Weiss-Tisman from VPR. And I see Mike Fisher. And I oddly, I wanted to read out the other ones, Kevin, who are not on our organization or is that fine? No, Abigail can write those down. Okay, because there's a talk too. Okay, great. Okay. So with that, we're gonna get started with our agenda. And the first item on the agenda is gonna be a discussion with Secretary Mike Smith from AHS about the CRF funds. And welcome, Secretary Smith. It's a pleasure to have you back again. And we look forward to learning more about the criteria and process for the funding. So welcome. Well, thank you. Can you hear me? We can. This is amazing. Just as I came on, we had a whole mess of technical difficulties as we were coming on. So thank you very much. I really appreciate the time. I wanted to talk about today just to give you a heads up of some of the things that we announced yesterday at the governor's press conference. Mainly it's not the ag grants. So you don't have to worry about that. But it is the healthcare stabilization grant program. And throughout this COVID-19 emergency, and I just wanna emphasize, we're not out of this yet. This is still a COVID-19 emergency. We've been focused on the financial stability of our entire healthcare system, including providers and array of social services, DAs, SAs, dentists, all along the lines of our healthcare system and social services. The reality is that preserving access to these essential services from our standpoint is required. We've got to buffer providers from the financial instability of business disruptions and increased costs resulting from COVID-19. It also means we've got to do our job of identifying the providers who are experiencing fiscal distress and offer financial assistance for those organizations to prevent providers from being forced to close their businesses. And here at the agency, we've talked about this before, but we have focused on that by providing response during this crisis in terms of retainer programs, payments to hospitals, financial assistance to designated and specialized service agencies, children to integrated services and private non-medical institutions and nursing homes. And in all, we've put out the door approximately $58 million so far in financial assistance that was provided to Vermont's healthcare and human services providers. I mentioned a list of them last time. We can provide that list as well. However, as we started to look at this in a much more broader sense, we started seeing them more was needed. Just the Vermont, we looked at, when we went out to providers and said, well, what do you need? We got a figure of $375 million. The hospital system alone is talking about $300 million in business disruption and increased expenses from the period March to the end of this year. Likewise, independent medical practices are talking about 10 to $20 million in order to stay fiscally stable. And the association of adult days services is talking about 2.4 million a quarter just for fixed costs and personal expenses. So we went to the legislature. And, Ina, if someone can start putting up after the overview slide, talk a little bit about what we did. We went to the legislature and proposed what was called a healthcare stabilization program with the objective of providing financial assistance to healthcare and human services. We originally asked for $375 million, $350 million in this fund. I think through the leadership of Governor Scott and with the leadership of the House and the Senate, we came up with a sum of $275 million of appropriations from the coronavirus relief fund. I will say this at the start because I get asked if this is enough. This will never be enough. This virus has really caused disruption throughout all industries and all sectors of the economy here in Vermont. And it won't be enough. But it is a lot of money, $275 million. And so the eligible providers, as we mentioned last time, is quite a ray of people. And I guess I'm not gonna have my slide deck here, but that's fine. I'll just continue moving. The eligible provider of organizations, that are Vermont-based healthcare and human services provider organizations in operation on or before February 2020 will be eligible to receive these stabilization grants through this program. Only billing providers are eligible to submit applications a broad array of healthcare and human services providers are eligible for the program, spanning from self-employed practitioners to peer services providers to hospitals. One of the things that I just wanted to talk about are the timeframe for these grants. We're gonna open up the grant submission that you can submit an application this Friday, July 17th. It will run until August 15th. And we will close that period. We're thinking of two tranches of, or two application cycles. The first being what I just mentioned, July 17th to August 15th. The second being in October. And the reason we're doing that is that, although there were great expenses from March 1st to June 15th, there are still some ongoing expenses that we wanted to capture in the interim period from June 16th to September 30th. Now, we know that one of the things that you have to do is spend these funds by the end of the year. So we can't have cycles go on forever, but we wanted to try to capture as much reimbursement and as much funding as we could in this. Now, if we get oversubscribed in the first period, there won't be a second round. And all applications will be reviewed after the period close. And this is a little bit different. A lot of the funding mechanisms that you've seen out there are first come, first serve. This is not going to be a first come, first serve. And we did it for a couple of reasons. First of all, the funding determination will be based on total need in the application. And we're gonna review it on need basis. And secondly, what we wanted to do is make sure that everybody had a shot at this. Just because you had a big accounting firm section in your particular organization, meant you probably could get the application done quicker. Then a smaller organization. And so what we wanted to do is make sure we had some equity and fairness in the system that a one person shop had the same shot at money as a 6,000 person shop. And so we wanted to make sure that A was based upon need and two, everybody had a shot at the same amount of money. So unlike other grant programs that you've seen recently, this is not first come, first serve. This is, you have an application period and then we will move through the needs at that point. Robin, I'm sorry, I didn't see your hand up until just now. Hold on just a second. Sorry, I'm not being able to unmute. Should I keep going? I didn't hear. Sorry, can you hear me? We can't hear you now. Okay, sorry, I don't know what was going on there, but the mute, every time I unmuted it would remute. So thank you. I had a question for you about your current thinking on the turnaround time for the applications, which I imagine is difficult to judge without knowing what kind of volume you'll get. As I'm sure, we start our hospital budget process the following week after August 15th, our hearing start. And just thinking for myself, I would be very interested in understanding which hospitals, assuming some hospitals get relief funds, got them and how much that would be in order for us to factor that into our decision-making, particularly around commercial charge increases. By the way. No, that's a very good question. We were thrown on a lot of resources to this to make sure that it's a quick turnaround time. We hope to have the money flowing out the door by September 1. So, I think that will jibe with the cycle. And we were thinking about that as well as we were putting the cycle together. So, that is our thought process so far, Robin. I'm sorry. Thank you very much. And thank you for considering our process as well. That's helpful. I just want to briefly say that it isn't, you put your name on and you submit in terms of an application. There is some process that is in this application in it. And the reason we have this process in the organization plus it's just prudent to have the process like this in the application phase. But also, we have federal requirements we have to abide by in terms of making sure we have the documentation. So, we're going to ask for organizational revenue in 2019 and 2020, COVID-19 related expenses occurred, financial release received a date from either the federal, our federal partners, state or other resources, organizational tax information to facilitate payment processing and a documentation to substantiate revenue expense and relief totals including in the application, W-9's income statement invoices receipts. We're trying to keep it as uncomplicated as possible but it's not, it is going to take some effort. We do encourage everybody to apply. We're going to have people that will help people through the application process. So, we do urge everyone to apply. And as always, there's some streams attached to this. One is the grant funds have to be expended by December 30th, 2020. That's a requirement of the federal funding. Grant funds will be used to cover costs and loss revenues associated with the COVID-19 disaster in accordance with the federal guidelines. Any resulting grant shall be funded with federal funds and subject to requirement of the single audit. And then, if applicable and this is a provision that I feel fairly strongly about, provider organizations will continue to participate in value-based payment initiatives beyond 2020. So, those are sort of the strings that are attached, the conditions, I guess I should not say strings attached, conditions to the grant as we move forward. Just for reference, you can see these are not new to you. I think last time I was talking about this program, I talked about, I gave you some examples. This is not an exhaustive list, but it's just about everybody that we could possibly think of that would qualify for the $275 million. So, I just wanted to make sure that you understood what we were doing, answer any questions, make sure you understood we did have in the back of our mind your budget cycle and trying to make sure that we were aligning it up at the same time, trying to get money out the door as quick as possible in the fairest way possible. And secondly, in making sure we could verify on a needs-based basis the money that was going out the door. So with that said, I'll take any questions. Questions from the board. It's Maureen, I just had a question on, when you talk about the financial relief to date from federal state and other sources, I guess how will you validate that? And if it was an independent and potentially they were able to get unemployment or different things, I mean, is there gonna be a validation of what was received as well? Yeah, well, we know where the $58 million went. So we know that, we know what money came in for some of the hospital relief programs as well. And we'll look at whether they participated in PPP, those sort of programs as they go. I don't have the exhaustive list of what we'll be looking at, but we will be looking at all types of those programs as we review their financials. Okay, and just another, I mean, I think the concept of having the two-time period sounded good because things are gonna happen in the future that we don't know about, but you also talked about if it's oversubscribed in period one, then there really wouldn't be a second round. And I guess if we were placing odds on if we thought it would be, I think my gut is it will be oversubscribed in period one, but do you have any indication there? I mean, to be honest, we control the throttle on that in terms of what goes on. If it's oversubscribed and there's a need, we're gonna get the money out the door. If we see a need that is in the future, we may throttle back some money just to keep it in reserve for that future trance. Let me give you an example. We provided relief up to with the designated agencies up until June. What their expenses are going to be after June, we just don't know yet, but that's one of the things that we're thinking in the back of our head. No, thank you. And thank you very much for considering our process in September one, we'll fit in there. It'll be a little on the back end, but we'll hold out on writing everything up until we understand how this flows through, but thanks. Kay, Rob and I see your hand up. Yeah, thanks. I was curious, Mike, what you were thinking about in terms of value-based program, were you speaking specifically of the Medicaid ACO program or were you considering other ACO programs by other payers or how broad and narrow are you considering that? I was specifically thinking of the all-payer model and making sure that there is participation in the all-payer model. Mr. Secretary, is there any type of scoring guidelines? For example, X amount of points if you're doing this and Y amount of points if you're doing that? We are, we have developed those methodologies for earlier grant proposals in terms of scoring methodologies. I am, I think those, what we're gonna be using is gonna be a methodology that is, that's defensible. I'm trying to remember, the answer to your question is, we haven't developed it yet for me to give you that answer, but it's not gonna be based upon the alphabet or name and there's gonna be a process here. Will everyone be notified whether they're given a grant or not? Yes. What's the promise? Okay, good. They will be notified. And also, I think I would like to see and I don't want to overpromise this, some preliminary indication at some point in August whether once we get sort of the preliminary scoring after the closing date, maybe some preliminary indication of where we're going with the grant application just to give them some heads up. Cause not only do we sort of wanna keep your deadline, we wanna give them some information about where we're going as well. Yeah, the deadlines are tight. You have to make sure that these monies are expended by the end of December.   On the first launch, we're gonna have to see the receipts. They're gonna have to send the receipts. I don't know the specifics of what we're gonna be looking at, but certainly they're gonna have to certify they're gonna have to attest to what they're submitting. And this might be, you know, everybody, everybody gets surprised on, it used to be Monday, Wednesday and Fridays because they used to call it that I used to do policy from the podium. I may be doing policy right here from the testimony. So, you know, but I think I'm pretty accurate in what I'm saying in terms of that. Okay, any other questions from the board? Yes, I see a hand up, Tom. Michael, Mr. Secretary, I'm just, what is there? So these funds need to be used for COVID related expenses, but is there any look back where an entity has covered an expense, but with reserves or scarce money and can supplant what the fact that they've covered it with this new grant program? Yeah, Commissioner Pelham, I think that is, your columnist secretary Smith, I'll call you Commissioner Pelham. I think that is eligible for funding. They covered the expense. It's an expense that they had or there was a business disruption because of it and they covered the expense. I think that's an eligible expense. And again, we have experts that are reviewing what we can and what we can reimburse for. Those will be in the guidances that we send out with the webinars that we're planning on having with the various entities that want to apply. But if you're asking me that in the way that you asked me, that's a covered expense. Kevin, I think you're on mute.  Did you have another question or you're muted too, Tom? I'm gonna take it. First time I've ever used the hand, so. There you go. Thanks. I'm getting practice here. We all are. It's a, you know, we just got used to Skype when we switched over to Teams. So with that, I'm gonna turn it over to public comment. And at this point, we'll take any public comment. And if you have a question for the secretary, please direct it through me. Any comments from the public? Hello, Kevin. This is Mark Stanislaus from the University of Vermont Health Network. Hi, Mark, go ahead. So it's not so much a question. It is just kind of a thought to share. And this might be on everyone's radar. As I understood the conversation is that the grants were intended to be used for cost and loss revenues for the appropriate periods listed of March 1st through June 15th and then June 16th through 930. And just noting that the hospital's fiscal year ends on 930. And when it comes to the matching principles on how we match this, we know revenue, it would be good to know, at least on the first tranche, on the second tranche, probably know, but, you know, for us to close our books for the audit purposes, you know, we really need to attempt to match up those time periods. And then also, there was a reference earlier to the FY21 budget process. And I'm trying to understand if these funds were, if the grants are gonna be granted for impacts prior to 930 FY20, how would that carry over to the FY21 budget process? So I can answer that for you, Mark, because as you know, in the guidance, you were given the ability to ask for two different components. And one was a COVID related component. And if you are receiving this type of help, it would have reduced really what your loss was because of COVID. And so that's why it's so important to us on our end because the last thing that we want is to grant a COVID piece to your rate and then find out that you've received X millions of dollars that would have covered that. Okay. What if you don't ask for a COVID piece in your rate? Well, then it... You don't need to answer that, Kevin. That's just, I'm just passing that thought out there. Okay, so don't feel... I'm not asking you to make policy from the podium. Yep. But I'll gladly answer as one board member, Mark, as long as it's reasonable and you can justify it, then you're okay. Okay, thank you. Any other public comment? Any other public comment? Well, Mr. Secretary, I think you're getting off rather easy today, but we really appreciate you coming in and walking us through this. It's very helpful to us as we prepare to embark upon the hospital budget process and trying to figure out how to calculate all the different money flows from a myriad of different sources and making sure that we sustain our hospital system, but not on the backs any more than necessary of Ramon or so. Thank you very much, Mr. Secretary. Thank you for having me. It's a pleasure. So with that, I'm gonna turn it back to Susan Barrett, who's gonna walk us through an introduction on sustainability plans. Sure, thank you, Mr. Chair. So the next item on our agenda is reboot of sustainability plans and update on financial health of hospitals. And I just wanted to lay this out for you in terms of who's doing what. So we're first gonna hear from Patrick Rooney, who's our director of health systems finances. He's gonna walk us through year-to-date data that we have, which is the end of May, and talk about the financial health of the hospitals reflected in that data at the end of May. But then we'll transition to the reboot of sustainability plans. And there are three staff members who've been working internally over the last weeks and months on the reboot of the plans. And we have Patrick Rooney, who's the director of health systems finance. He has provided a financial look at the plans. Then we have Jeffrey Batista, who is the chief of, he's a data and analytics information chief for us. And he's going to be working with us and has helped us on providing data that we will use in looking at these plans and in populating these plans. And then last but not least, we have Elena Baribi, who is the director of value-based programs and ACO regulation. And she will provide the health systems policy lens as it relates to these plans. Once Patrick has his update on the hospital financial health, we'll turn it over to Elena, who will run us through the slides on sustainability, but we'll have Patrick and Jeff also interjecting and available for any kind of comments or questions. And then I'll just close by just reminding folks and Elena and the team will go through this when they talk about the reboot. It was back in February of 2020, which sounds like it feels like a lifetime ago that we actually talked about sustainability plans. And after the COVID crisis, we put these obviously on hold, but we did work internally staff level to look at a way that we can reboot these and produce an updated framework that takes into consideration COVID and everything the hospitals have been through and are quite frankly still going through. So, and then last I'll say, you know, this is a proposal. We'll have this out for public comment and we look forward to hearing from the public and others on the framework. So I'll turn it over to you, Rick, to provide a financial update on the hospitals. Thank you, Susan. Good afternoon board, good afternoon members of the public. Can everybody see my screen? I cannot. You cannot. Not yet. I think Abigail, if you can't get it up, maybe Abigail can work on getting it up on our screen. We may have to do that because I'm getting a message that desktop sharing is not supported on this yet. Huh, okay. Abigail, can you try to project? Great. Thank you, Abigail. Thank you, Abigail. Okay, so as Susan alluded to, we are going to review the year to date, May 2020 financial performance of Vermont's hospital system as a prelude to the reboot of the sustainability plans. A lot has occurred in the last several months, which has impacted the way those sustainability plans have been reconstructed and will be discussed today. So Abigail, if you could navigate to the second slide for the folks at home. We wanted to bribe a brief overview of how we got here. It was not that long ago that COVID descended upon the state and it was March 7th, where the state of Vermont announced its first presumptive case and less than a week later, the governor declared the state of emergency. And as Secretary Smith discussed earlier, we are still very much involved in the COVID situation, even though Vermont has done a spectacular job of bending the curb and becoming a national leader in COVID mitigation. That state of emergency was extended yesterday. So we're still very much involved in this situation as all of our hospitals are and their employees are well aware. The next couple of bullet points are very important to the discussion we're gonna have today because within two weeks of that first presumptive case, the governor ordered the suspension of all non-essential medical and electric procedures. That had a major impact on the net patient revenues of Vermont's hospitals. And it was a week later that the president signed into law the CARES Act totaling $2 trillion, a portion of which will be going, did go to healthcare providers around the country. And in April and May, the hospitals in Vermont began to receive some of those funds. In addition to that, Medicare and other payers provided dollars for advanced claims that although incurred debt offered, cash flow relief should hospitals need it. So Abigail, please navigate to slide number three. So we'll come right out and show the situation that the hospitals have incurred in during this fiscal year. And as you can see, for the first several months, the system-wide operating margin varied. There were some months in which margins were good and some months that margins were bad. As February approached, we began to hear whispers from hospitals that some of their appointments were being canceled voluntarily out of fear of the unknown that COVID-19 was possibly even here in the state of Vermont, even though we didn't have a presumptive case. And we began to hear more and more from hospitals that some of those electric procedures and physicians appointments were being canceled. And that was looking back was kind of the early warning of what was to come as we looked at that in hindsight. And then in March, you can see collectively in that green column that the hospital system lost nearly $53 million. And that is with the voluntary cancellations going on in early March, but more so the cessation of those elective non-emergent procedures in the latter part of the month. There was a minor rebound in April and further recovery in May, largely due to the infusion of those stimulus dollars to help offset some of the losses that the hospitals were incurring. And even as you move towards May, what we begin to see is the first initial stages of reopening our hospitals and revenue beginning to flow back in for providing patient care services. So just for a point of clarification, Patrick, maybe you can explain that these numbers don't include all the losses because people put in place some of those relief dollars into their financial statements, but not all of them. So this isn't really a true picture, either way of losses or of what is left of those dollars. So in either- That's correct. Context here is very, very important. Under normal circumstances, we'd be looking at a month and on a here and now basis, but because the situation as it relates to COVID is so fluid, that's difficult to do. And as we move through this, we'll discuss why some of these figures aren't realizing all of the stimulus monies that have been received by hospitals, but perhaps not realized in the system. And we'll move to that as we go through the presentation here very shortly. So Abigail, if you could navigate to slide four, please. This is a rollup of the year to date situation in our hospital system. And as you can see those initial months beginning at the fiscal year, it was very, very mixed results.  And then as February approaches, you begin to see this departure. And in March, the declines grow very, very rapidly. April, even though matters improved on a singular month basis, there was still almost a $24 million loss incurred in our hospitals, which drove that year to date figure to almost $87.4 million. And with a minor rebound in May, the situation currently is an operating margin loss of $77 million for all hospitals in the state of Vermont. Slide five, please. So we wanted to provide a kind of a before and after point of view here because as I've stated and will state throughout this perspective is very important. And when we look at fiscal year 20 budget and actuals, we had a budget to actual variance just about negative 1.6%. And as that compared to the same period prior year, budgets were MPR FPP was running about 2.8% compared to prior year. And that includes the charge increases that the board approved back in September. And as everybody knows, they try to contain those increases in MPR FPP to 3.5%. So the system was operating year to date within that threshold. So matters were moving along in the system. And there wasn't a whole lot of discrepancy there or variation. And as we move forward on slide six, please, Abigail, we will see that the situation has changed dramatically. The budget to actual variance is now negative 13.1% and compared to last year MPR FPP growth is down 9%. Budgets have been busted by COVID. And this is where our hospitals are finding what we call a revenue gap. And this is actual to budget. And you'll see that 1.796 was the year to date budgeted MPR FPP. The reality now is that it's at 1.561. It's almost a $235 million variance actual to budget year to date, May, 2020. Slide seven, please. Moving into operating expenses. And again, providing that fiscal year to date, February, kind of that pre-COVID look, budget to actual variances on operating expenses were around 1.8% and actual to actual operating expenses running a little high at 6.2%. So we knew that was happening along the way. There's obviously UVMs operating expenses hold a greater weight than most of the rest of the system. So as we've said before, as goes UVM, so goes the system averages. And you'll see there, they were running about 9% over their prior year comparable as of February, which drove that system average into just north of 6%. Slide eight, please. And here we are now. Budget to actual is almost break-even. It's almost directly on target. And actual to actual has come down almost 50%. And we've seen cost reduction efforts listed to us in monthly reporting from hospitals that range from furloughing of staff. That's probably the most public cost reduction measure that's taken place throughout this. There's also been benefits freezes, leadership pay cuts, capital project suspensions are a big part of this, money not being spent on investments that may or may not be recaptured in full given the suspension that's had to take place. And also reduction in cost of supplies for elective procedures that the hospitals simply aren't purchasing because they weren't able to do those procedures. So that's really brought expenses growth more in line with budget and prior year actual. Abigail, if you can have me to slide nine, please. So here's another view of the busted budgets that I alluded to earlier. In the blue, you'll see the budget to actual May fiscal year 2020 NPR growth, if you can call it that, compared to the same period prior year. And there's only two hospitals on there where it's even close. And one would be Gifford and the other one would be Springfield. The other is it is a large disparity in NPR and that's creating that revenue gap that we spoke of earlier. Slide 10, please, Abigail. So one of the factors in this, and this is what Kevin was discussing earlier. These are from the folks at Vaas. This is the most recent information we have on stimulus funds to date. And those CARES Act funds are distributed in three tranches, the last being a rural stimulus relief package that Health and Human Services released in May to rural hospitals and hospitals with very high COVID admissions. And every hospital in the state received this rural relief funding with the exception of the University of Vermont Health Network. One, they are in what CMS considers a metropolitan statistical area. And two, their COVID admissions did not reach the threshold that Health and Human Services had set forth for receipt of those funds. Now, as Kevin discussed, it's important to understand that our hospitals have received $115.4 million. They haven't necessarily realized that on their income state. They're using an accrual method by utilizing a, what they call a deferred revenue account, which is a liability account. And what happens is when they received those funds, they parked them in that account. And then on a monthly basis, they will release a portion of them onto their income state. We've had hospitals say, we're just getting back to break even. So we release whatever amount we need to cover the shortfall and operations. Some hospitals are utilizing it to get back to their budgeted levels to cover those shortfalls. So the ultimate result of gains or losses is not really gonna shake out until matters smooth out towards fiscal year end and maybe even beyond in some cases, depending on what occurs in the future. So that context is very important. And with the graph to the right on slide 10, we wanted to try to show hypothetically what that would look like had they realized those stimulus monies in the periods in which they were earned much like they would with NPR. So you have prior year to date May 2019 NPR 1.713. Year to date actual NPR through May for 2020 is 1.561. They actually did realize all of those funds still would only get the system 1.676. So even with all of that money being infused, had they realized it as they do NPR, we'd still be 37-ish million dollars short of the same period prior year when it comes to NPR. Now that is just us trying to visualize for the folks here what the situation is in regard to the impact that cessation of electives have had in the reaction to COVID on our hospitals. Abigail, slide 11 please. So this is another view of the budget to actual variances and actual changes for NPR and operating expenses. We've already covered it, but we put this in there to give folks a hospital by hospital view of how this pandemic has come upon each hospital. There's a lot of similarities that hospitals had to react to. They all had to stop elective procedures. They all had to scrounge and scrape for increasingly expensive PPE and they all had to prepare and alter floor plans, et cetera to make their institutions safe for COVID and non-COVID patients as well as their staff. So everyone's had those similarities, yet the actual impact of COVID admissions and treating and caring for those patients and testing whatever has different. So you will see variances at each hospital that differ based on their own specifics and circumstances as it relates to how they've had to deal with COVID. Slide 12, please. Finally, in the income statement side, here are the hospital by hospital operating in total margins and they are difficult to digest. They're on a scale that is unprecedented in our state and it shows the severity of COVID's impact and that actual impact as I was just alluding to does differ on a hospital to hospital basis and those cost reduction measures being employed, the volume and diversity of elective procedures that were offered and the accounting methodology that we discuss is going to skew these numbers a bit. And if you look on operating margin, you zoom in on Gifford, Gifford is showing a positive 1.876. Well, what Gifford was was almost 1.876 in February. They had a very difficult month in March with the cessation of procedures. So when those monies began to arrive, they were released, they took them and put them in that deferred account and they began to release them to cover that loss. So they took back their loss and every month since, they've released just enough to break even. So it is possible that at the end of the year, they will come out at a level that's pre-COVID. Now there's a lot of variables there. Their volumes have to return to an acceptable rate and the money that they've received has to see them through by covering those losses. But that's why you'll see something like get that in there and it really does depend on what shakes out at the end of the year. When you look at total margins, total margins have really declined. There's another $30 million on top of the loss for operating margin and COVID's financial impact is not segregated strictly to healthcare. A lot of the income streams that cover sometimes operational margin losses in normal circumstances are derived from non-operative income specifically from investment portfolios where securities are invested in global markets. We all know that in March, the global markets went into free fall as the world shut down and the investment portfolios, no matter how conservatively invested, were not going to escape that fact. And there has been some rebound in May and April, but not enough to recover what's been lost so far year to date on total margins. Abigail, slide 13, please. And now we're going to move into the balance sheet side. Everything that rolls out of the income statements on a monthly basis rolls into your balance sheet. And we're going to specifically look at some of the current assets and current liabilities because those are the sections of these balance sheets that we're seeing are most impacted by the fluctuation in finances that has occurred as it relates to COVID. We're not seeing a lot of long-term assets or as we would call it your long-term assets, your plant, your equipment, et cetera, because nobody is really making heavy investments, capital-intensive investments right now. So we'll start off with the cash and the short-term investments. And if we look at fiscal year 20 May, compared to fiscal year 19 May, we have about a 127% increase in cash and short-term investment balances. So people may be at home going, wow, the hospitals are liquid right now, they're cash rich. I would not take that context with you because this is essentially a liquidity facade. We have going into those cash balances, the stimulus funds that have been provided to the hospitals, Medicare and other payer advances, potentially draws on lines of credit and other short-term borrowings like the SBA PPP loans that are sitting in there. Most of those will have offsetting debts or liabilities in current liabilities on the other side of the balance sheet that we'll talk about. In addition to that, these monies that have been given to them in the stimulus have to last. They have to last as long as they possibly can because volumes may or may not recover to the extent that hospitals are used to. There are safety protocols in place now and social distancing or whatever that hospitals have to abide by, which may slow the return of those volumes. There's also people's potential unwillingness to go back to hospitals still. And really hospitals can only catch up on volumes as fast as their staffs can work. So there is a threshold there in staffing that can only take them so far. So those dollars have to go a long way. In addition to that, as the months go by and this is where context matters, it could change drastically between this May report and the June or July because those Medicare and other payer advances are going to require a reclamation and they're going to be clawed back to some extent. So these balances are going to come down as those are repaid and they're going to come down as those cash balances from the stimulus are used to offset losses. So we'll look at those days cash on hand all the way to the right and they've ballooned. A lot of that is going to have to be repaid and a lot of that is going to be used to cover those losses. And that's an important perspective to take away from this because it's not a system as of right now that anyone could say is somehow benefiting outrageously from stimulus dollars coming in. That money has got to last. That's the important thing. Abigail, slide 14 please. So we'll move into accounts receivable balances and due to the cessation of elective and non-emergent procedures, all hospitals have seen a reduction in revenues. And as those revenues decline, those revenue centers are suspended and those revenues decline. The AR that is being collected will drive down the balance in collaboration with the fact that those suspended revenue centers are not producing sufficient revenue to refill those accounts receivable balances. Inclusive of that, when we look at the days receivable the columns on the left or the right where the days receivable is located the average of 19 and 20 only comes out to a three-day differential. In 2019, the average system days receivable was being collected at 39 days compared to 42 in fiscal year 20. So they were still collecting AR at a relative rate. However, the volume coming into their revenues was not sufficient to replenish that and in April AR balances for the system dipped to 144 million. And at the end of April that represented about five to six weeks during a period in which they were not able to earn on a large portion of their business. And when you look at this you'll see hospitals like Copley and Rotland and Southwestern where those days really came down. Part of that is the balances came down. And it looks like there was and amongst other hospitals here there was a vigorous effort to collect as much as you can. You cannot pay your bills with the accounts receivable balances. Cash is king, that is important. So you'll see those days coming down very quickly. The hospitals where you see increases all have something in common and I'm not sure it correlates, but it is interesting. And that is the health network hospitals and Brattleboro, North Country and Northwestern. They're either at or above where they were last year. Subsequently, all of those hospitals have in the last year and a half implemented and integrated electronic healthcare records or financial software into their systems. And those often come with some slight hiccups and maybe the reason those balances are up, it may not. But it is interesting that of all those hospitals, those have all had software implementations in the last year. Everyone else is on the decline. Abigail, next slide please. This is an area that doesn't often get much attention. These are the board designated assets. And these assets consist of items designated for variety purposes, some with and some without restriction. Much of them will be the investment securities that we spoke about earlier. And you can see from the colorful graph at the bottom there in the orange from February to March, there was a significant decline, about a $90 million decline in the system totals of those balances. Some of those investment portfolios were likely liquidated. A portion of them were liquidated to make access to short-term cash early on when it was very unclear what any government help would look like. But most of that is a devaluation in market activity. And you can see the rebound corresponds to the rebound in the markets. It is important to note that this is a year-to-day look and at the end of last year, a couple of things happened. At the end of last fiscal year, Porter Hospital transferred the majority of theirs over to the UVM Health Network. And in December year end, the UVM Health Network, I believe, had to make due on a pension obligation that was funded out of these board designated assets. So the value of them was naturally down. But the interesting part here is the February to March impact on those. And the less money there is available in here, a lot of capital improvements and new programs are funded out of the money that's churned off of this. So it's important that these balances remain somewhat relative to their historical areas because hospitals need to make those investments. Those are very, very important. When these take hits like they've taken, it puts a lot of that at risk. So we wanted to focus in on that as well as we move through our analysis here of the hospital. So Abigail, the next slide, please. All right, slide 16. Here we're getting into the current liabilities. And we look at that year-to-year, year-to-date comparison, we'll see about a 78% increase or almost $300 million over where current liability balances were last year. And current liability balances like AR are susceptible to the nature of timing and business operations. But with an increase like that, there's obviously something else going on. And there are several causes for this. Short-term debt incurred from the acceptance of, and perhaps not usage of, but acceptance of, Medicare advance claims and other payer advances, draws on lines of credit, other short-term borrowing, strategic and necessary delays and paying vendors, and the use of those deferred revenue accounts that will release and realize over several months those liabilities into income. So when you look over at the days payable, they are ballooning. And again, often times when things are as uncertain as they are, CFOs know this best, cash is king. There we are again. And they will delay paying bills. Oftentimes vendors will offer discounts.  Well, if the value of those savings is less important than holding on to the cash that you have to go out to pay those bills, you're gonna hang on to it. And we are seeing, along with the balances here, we're seeing those days payable rise. So there's a couple of things driving up those days payable days. Next slide, please Abigail. Okay, fund balances to wrap up. We put a little note on the side to explain the fund balance. It is the equity position of the hospitals. And it has been impacted by the fluctuation of financial activity that we have experienced year to date and most importantly in the last few months. And overall system wide, it is down about 3.9%. And it could have been a lot worse if it hadn't been for the cash infusions that were provided by the federal government via the CARES Act because losses roll into here. And when losses roll into here, you're paying out your cash to cover those losses, which depletes your asset position, which depletes your equity position. You may also have to borrow money to meet those short-term obligations. So as that equity window shrinks, your financial position becomes more precarious. You always wanna be on the positive side of the equity situation. And if you're not, something is going on. So it's okay to see things holding where they are right now. There is a lot of variables and unknowns ahead of us. And when looking back at March and the fear that everyone had about where things may be in July, it's not too bad, all things considered. The situation with the $107 million total operating loss is not great, but there's been an infusion of liquid assets to offset those losses. And that is very important because that means the hospitals aren't utilizing their own resources to cover those, which is keeping this equity position relatively. And so that concludes the presentation. Again, in context and perspective of what we have here, there's a lot unknown in the future. Matters are gonna change month to month. And further out, we are hearing from hospitals the encouraging news that volumes are rebounding. And that has to do with Vermont's achievements of bending that curb and instilling confidence in its healthcare institutions. And that's very important. We hope that continues, but the resources at hand right now are not endless and hospitals are making do with what they have to offset those losses. So hopefully these volume rebounds continue throughout the summer and our hospitals can end up back where they were pre-COVID of patterns continue as they are now. So. So I see that Maureen has her hand raised. Yes Maureen. Yes, my hand was raised. First time I use that feature. Now this is very helpful as far as going through what happened. Can you go back to slide 12? Is it possible to go back to the slide pieces? So I guess the first thing is something that Kevin touched on earlier, but one of the things that's gonna be really important is to understand what each hospital is doing with the funds that they received and how they're recording them. So I think in the June request, and it may even be a budget request, just understanding how much money each hospital received and where they're categorizing it, if they've put it into income or if they're still holding it on the balance sheet and putting it in monthly and things like that. But then, because that then plays into this slide, I think what would be good to see on this slide in the future would be to compare it against both budget and finance. Because this kind of takes into play both what happens with NPR and what's happening with expenses. So that would be something to look, because here where we're saying we have a system loss of 77 million on operating margin, but there obviously was a positive operating margin that we expected. So I think it would be important to see that potentially in June. And I don't know if you have any numbers on that at this point, Patrick. We do not know. And to your prior point, we do have the question out to hospitals in June about accounting methodology and how much of the funds that they've received have they released and realized into the end statement? So we'll have an idea of what's left. And we can even explore that question again as we get closer to budget season, because as we said today, it's going to change quite a bit between now and then. So it's going to be important to have up-to-date information going into the budget cycle. Right, right. And then on slide 16, when on the current liabilities, you know, there's probably multiple things driving that, right? One is going to be the loans that they received. I think that was what, about $160 million or so, or $130 million. The other thing that would be good to see is how much payables, the change in payables is driving that because that would be reflected in their P&L, but not in their cash. And then understanding if there is a third component of additional borrowings. So I don't think we have, we know how much stimulus loans are, but we don't necessarily know how much the fact that we have a hundred days payable is contributing here. So that may be something for June too, just to understand what additional debt people have taken on. Okay. Just to tack on to what Maureen is saying too, Patrick, we're going to need the couple of hospitals that have received PPP funds or should receive PPP funds if the court so allows. So for those approximately three institutions, we're going to need to know the percentage they believe is going to be totally forgiven. Okay. Yeah, I mean, but this is good, a lot to unpack, obviously, but you know, I think this was a good look that really shows the impact of what's happened through May. So thanks. Any other questions from the board? Not seeing any. I think we're going to continue on with this presentation and after all three have presented, then we'll open it up to the public. So Patrick, make sure you're hanging out. I will be here. So Elena, are you going next or is Jeff? I believe I'm going next and Patrick and Jeff will chime in as necessary. That works. And I am in the office. I just took off my mask, I'm alone. The first time I'm here, well, didn't even, more than six feet, but anyway. So I'm going to share my screen. Let's see. Let me know when you can see it. You can see it, we can see your name. Okay, so just so everybody at home knows the reason why you're there is that you need the solid internet connection when you're doing a presentation. Yeah, and you know, I would add solid internet connection across the board. You wouldn't need to be there. I wouldn't. I could be safely at home, you know? That's okay. We'll just make do. So as Susan mentioned, this has been a work that spans across board staff. So I've been working closely with Patrick and Jeff to put this framework forward. And so today's structure of the conversation we're hoping to have is, you know, I think Patrick did a very thorough job discussing hospital financial. So we'll breeze through some of those slides that might look familiar, reiterate some of the national and local trends in hospital sustainability that we've been witnessing across the US and here in Vermont. Goals for the sustainability planning framework that we kind of started working from a number of months ago. We'll provide an update on the framework and then talk about regulatory integration, you know, sustainability and the all-pair model, kind of that intersection and one of the many intersections of these two kind of concepts. I will talk about next steps. And then if, you know, should you at home wish to look into kind of what we use to build the framework, there's an appendix at the end. So now I'm on the slide. We're going on to the next slide. Maureen, I see your hand is up. Is it just that you haven't taken it down from earlier? Yes, I don't see it up, but I don't know who takes it down. I think you have to. There you go. Okay. Okay. Great. So I will continue. So, you know, Patrick mentioned earlier, Vermont hospitals have seen operating losses collectively of 77 million for, you know, year-to-date as of May. Total margin losses are passing 107 million and, you know, a variance to budget of 235 million. So while hospitals have received, you know, 115 million federal stimulus so far, it's hard to tell right now how much of that applies to these losses. And so after the June year-to-date collection, we should have a better idea and be able to capture those details more precisely. So, I mean, you're all aware of this slide and I think this number keeps ticking up, which is why we're here today. So since 2005, there've been 170 rural hospitals that have closed nationwide. And 2019 demonstrated higher rates than any previous year. And, you know, 2020's not over, but it's certainly already keeping pace. As of 2019, 25% of rural hospitals were predicted to be at mid to high level of financial distress and not a very pretty picture. And then I just wanted to share this disturbing statistic with you in light of kind of what we are seeing for our hospitals is in a recent health affairs article published just last month on the viability of US rural hospitals. It highlighted and found that a median overall profit margin of 3.2% was the profit margin for hospitals that closed and that was the margin in the previous year before their closing. And they looked at approximately 1,000 hospitals over 2011 to 2017 and found looked at different characteristics that were associated with closure. But, you know, it's still hard to tell with all the funding exactly where we are right now, but the three point negative 3.2% is not terribly far. So I think that kind of reiterates the concern that the board raised earlier last hospital budget season but is now even more pressing in our eyes. So, you know, post COVID we've only seen this issue exacerbated. So the hospital AHA estimated $202.6 billion in losses for America's hospitals and health systems, 50.7 billion per month. In April alone, hospital operating margins dropped to negative 29, which is a 282% decline relative to the same period in 2019. And this really reiterates the challenge with a fee-for-service system that is really insufficient to accommodate such severe swings in utilization. And this slide should also look familiar. It describes and shows how expenses have continued to outpace revenue growth, which contributes to the declining margin that we're seeing in Vermont. And this was as of 19. So I expect that 20 will look even worse as it comes to a close. And I think Patrick actually had this pretty much exact slide that just demonstrates, you know, the system-wide operating margin of negative 77 million and total margins are only about, you know, negative 107.2 million. And this is quite concerning. So, you know, this is not the first time that we've talked about hospital sustainability. This conversation really started before the onset of COVID. There were already many indicators suggesting that Vermont was on a path that needed to be considered, you know, April 3rd of last year. The board held a panel on rural health care. The legislature enacted Act 26 of 2019 to establish the Rural Health Services Task Force, which produced a report and presented it at the last legislative session on some of the findings there. And then the board memorialized their concern or your concern in the 2020 hospital budget orders. So this requirement started with six of 14 hospitals to submit a sustainability plan. And as I mentioned, COVID has clearly only exacerbated this need. You know, there have been a number. You know, it's not just the board that's paying attention to this. The governor, certainly AHS, you know, Mike Smith's testimony earlier, alludes to the same concerns that we really need to think about. So the sustainability of our system. And, you know, I think the state has all hands on deck here to try to figure out how to best do this and ensure that for monitors still have access to essential services. So just to, you know, I think we presented this last time, but just want to reiterate, you know, this is really about engaging in a robust conversation on community access to essential services and the barriers to sustainability. So this is not a one and done exercise. I think this framework is just a proposal for what we would really like to see and consider and find a way to weave into the hospital budget process, which I think echoes some of Baz's initial comments about really combining the sustainability conversation into the hospital budget process. You know, I think this framework, we really want to encourage hospital leadership boards and communities to work together to address these challenges and to incorporate them formally into hospital strategic plans over time. I think this framework allows hospitals to identify hospital led strategies to right size hospital operations as well as identify external barriers that could help them more aptly adjust their sustainability. So, you know, other stakeholders, policymakers and regulatory bodies also have to come to the table to, you know, like I said before, this was really an all hands on deck approach. And I think this framework is information gathering to further that conversation. And I think, you know, despite just influencing the hospital budget process, we really need to enhance our regulatory integration work and leverage these insights into planning for a subsequent agreement. So how should we consider and should we add a fourth prong to our all payer model goals that that hospital should we, I think we should add a fourth prong on sustainability and how we consider that going forward. So I will first start by highlighting at a high level. I'm on slide 11 for those of you who are following along with the slides in your hands. So we'll review the proposed changes in response to COVID-19 at a high level and then go through the framework. It's generally the same theme, but I think we've kind of clarified and gotten more detailed on some of the questions and metrics taking into consideration feedback we've received from various audiences. And then, you know, I think, you know, what you'll see here is that we have expanded this framework and the approach to all hospitals. This is, you know, in recognition of Oz's comments from March 11th that we really have to consider the sustainability of Alderman Hospital. They think this stands especially in light of the pandemic that, and as Patrick, you can see from Patrick's presentation that this is really now is the time to think about this. A phased approach, we would like to, you know, find a way to limit the administrative burden on hospitals. We recognize this is a really big list, but, you know, given the kind of critical nature of the questions that we're asking and the concern for the larger hospital system, we really feel strongly that this is the right time and the right level of detail, but recognize that we might have to work on, you know, when and how we collect these data. So, you know, looking for feedback there. But we've also incorporated specific questions and learning from the COVID-19 experience thus far to inform this framework. There's, you know, certainly we can't predict what lies ahead, but to the extent that, you know, there have been delivery system changes taking place in, like, telehealth, et cetera, we would like, you know, that thought to be part of this work. So, stage one, so this, you know, as I mentioned before, we're trying to break it up into four stages. It would be done at separate points in time, and the first one is really focused on hospital financial health. So, in this first stage, the Green Mountain Care Board will provide a summary of each hospital's financial health based on regional and national benchmarks. The information on the hospital's financial health will come through data submitted through the hospital budget process, claims data from B-Cures and Medicare cost reporting data, which is new data to the board that we've actually acquired for this project to alleviate additional reporting done by the hospitals. And then through these metrics, for those that are classified as vulnerable or highly vulnerable on a certain benchmark, we ask the hospital to provide commentary. So, to outline the specific action steps to be taken to bring them into the adequate zone or to get them out of the vulnerable or highly vulnerable classification, the time that would be needed to achieve that milestone, and then potential obstacles to success and strategies to overcome those obstacles. So, you know, it's kind of like a work plan on a metric level, and just, again, to further the conversation. Stage two, so we'll talk about timeline later, and that's certainly something to discuss, but stage two would kind of bring the conversation to focus on essential services, and we rely on a definition taken from the American Hospital Association's Task Force on ensuring access to vulnerable communities. And this includes primary care, prenatal care, home care, dentistry, psychiatric and substance of these services, emergency and observation services, diagnostic services, transportation and a robust referral system, and transfer agreements for specialty services. So, you know, we want to leverage existing work and use definitions that are already kind of industry standards, and this is one of those areas. So, as it pertains to these essential services, we would ask hospitals to comment on each service line, our community needs for that service, it's mostly not met, partially met or fully met, which entities deliver these essential services? So, is it at the hospital, the SWHC, your designated agency, independent providers, et cetera, which it might look very different depending on what community you're in. And then we would ask that you provide some financial metrics for those service lines. So, contribution margin or total margin, we're just looking for a positive or a negative here, doesn't have to be a dollar amount. And then estimate the following, average price ratio, charge markup, average Medicaid to Medicare reimbursement ratio, payer mix and percent contribution to NPR. And those are defined in a more detailed fashion in the framework, but I'm happy to talk about that later if there are any questions. So, ensuring the provision of essential services hospitals will also be asked to answer the following questions. So, what percentage of NPR does that essential service line contribute to? And then for the essential service, what are the obstacles to sustainability to delivering those services fully in your community? And then what are the obstacles that can be undertaken by the hospital and those that require involvement by other stakeholders, regulatory or policy bodies? So, recognizing that this is not all on the hospital shoulders. So, the sustainability of other services, again, I think this is outside of those that are determined to be, not determined to be essential, but defined as essential services by the AHA. I think we need to think about the value-based environment to which our state and much of the country is moving towards and CMS is moving towards. And how do we think about sustainability in the community, continue to access to essential services? And how do we think about these other services that hospitals are also pursuing? And can the hospitals deliver these services at a high quality and low cost? Are there, where volume has been correlated with quality for surgical procedures, for example, is the volume sufficient to constantly, consistently deliver quality of care? And is the delivery of these services efficient as we consider capacity and utilization? And then again, similar to the previous stage, hospitals will be asked to comment on the financial metrics or to provide the financial metrics on the particular service line. Again, contribution margin and total margin are simply positive or negative. And then we would look to have estimates for the following financial metrics, the same as user metrics as before. And then in addition, for these other service lines, what's the distance to the nearest alternative provider? Is there service line growth potential? Does this service line support an essential service and how? And is this service line would be included in an optimal service line in a value-based environment? So I think that's something we'd like to know. And then does CMS require this for hospital designation? So hospitals are asking, for those other services, hospitals will be asked to look at capacity and procedural volume for surgical procedures only. In terms of capacity, we're looking for a monthly minimum maximum and average of staff bed occupancy rates, ED visits per day, and number of births if there is a birthing center present. For procedural volume, listing any surgical procedure and its volume if it's less than 25 times per year per position or fewer than 100 times per year by the hospital. And these thresholds are kind of taken from the literature. And then there are a series of follow-on questions to understand more nuanced and hospital-specific information delivery of these other services. Has the hospital forecasted the demographic changes that are expected? And what does this mean for their strategic planning and utilization expectations associated with essential services and other services? How does the hospital anticipate these demographic challenges will impact workforce associated with current and future remonters, traveling nurses, contracted labor? And then for service lines with negative contribution or total margin, is there a documented community need for this service? In addition, for services with charge markups greater than 150%, we're looking to describe strategies to bring down the cost of delivering those services to commercial patients. For procedures identified in table four is that capacity, sorry, procedural volume. So that's for surgical procedures only. Where hospital volumes lie below 50% or below 25. Please assess whether the surgical volumes are sufficient to maintain low-cost, high-quality outcomes for patients. Can the hospital deliver each of these services listed in table three? So that's about capacity in a high-quality, cost-effective and sustainable manner. If not, what steps can the hospital take to optimize service line delivery? And then thinking about whether or not services could be delivered elsewhere if it looks like it is problematic. So describe what an optimized service line looks like for the hospital and assume there's a scaled up value-based payment model focused on primary and prevention and population health where hospitals are held accountable for cost equality. So while we're still in transition to a truly fully implemented value-based model, it's never too soon to continue planning on a local level. And then what steps will the hospital take to ensure that the patients have access to divested services through referral transportation options? We don't wanna eliminate services altogether, but we wanna be thoughtful about how they are delivered. So has that been a consideration? And then will the optimized service line strategy in response to eight impact the hospital's ability to respond to a public health emergency? So I think we recognize that with COVID, we didn't have a lot of slack in the system. So where is a balance of efficiency and being able to adapt and flexibility? So I think that is also a consideration in these responses. So stage four is the final stage. So in this section, hospitals are asked to reflect on the information and analysis found in the prior sections and discuss their plans for sustainability as they consider delivering essential services to their community in this value-based world. And I'm on slide 22. I apologize for not continuing to provide guidance there. So stage four is really just a series of questions. So I'll go through those now. So given the financial headwinds facing rural hospitals, how can your institution balance the need to deliver care to rural patients who might be older, poorer, and less mobile than other patients that the need to ensure that services delivered in the community are delivered low cost and high quality. And then please describe how hospitals will ensure delivery of high quality essential services to all members of its community at low price to all payers. And then please describe any current and future obstacles to sustainability and fully delivering cost-effective high quality care in your community as envisioned in the optimized service line. Additionally, hospitals will be asked to offer possible solutions to those obstacles that can be undertaken by the hospital and then solutions that could be addressed by other stakeholders, policy bodies, et cetera. And then how might payment reform mitigate some of these financial sustainability challenges whether global budget capitation or some other payment reform mechanism. And then we ask also for hospitals to describe their relationships with other care providers in the community as it relates to your work and investment in prevention and population health. And what are the challenges and opportunities for improving how you work together to achieve better population health in your community. So leveraging that value-based approach and thinking about how we can further that work. And has the onset of COVID impacted service line decisions for both short and long-term, please describe any service investments or divestments related to your COVID experience. And then given existing financial and economic pressures faced by hospitals and the goal of delivering high quality low-cost care which assumes lean operations as we mentioned before, how are you simultaneously planning for another impending crisis. So either second wave of COVID but also potential future pandemics. What's the right balance here? And then provide a summary of your hospital's application for and receipt of funding related to the CARES Act and coronavirus relief fund or other pandemic related grants or loans to the extent that we don't already have that information. I think we can make clear what we have when this stage rolls out to alleviate administrative burden. And then what assumptions and utilization expectations are you building into your budgets and forecasting? Have these methodologies changed with COVID-19? And then please attach any documents pertaining to strategic or sustainability planning that's already in place. So this is a proposed timeline and we recognize that this is a significant lift and I think we're certainly willing to work with stakeholders to figure out what the right cadence is. But I think the goal here and as mentioned in the Vogue letter is to make sure that the sustainability framework can influence the hospital budget process. And so March is approximately when hospital budget guidance really takes off for 2022. So I think any lessons that can be learned from the sustainability framework and then how we can leverage what we've learned from this exercise and kind of rolling it forward into that process would be immensely helpful. So we've proposed, if we issue the framework by August 31st, we could implement stage one by October 31st, then we have November 30th, December 30th and January 31st, first stage four. And recognizing certainly that COVID-19 is an additional layer, we don't know what this fall brings but that this may need to be adjusted accordingly to those needs as well. So next steps for the sustainability framework and I'm sure this is not an exhaustive list. I think we could have a potential board vote today to expand sustainability planning to all hospitals which is part of the Vogue public comment from March. I think we could open this up for a second public comment period until July 22nd to allow time for additional public comment to this latest version. And then GMCB staff can continue working with stakeholders to finalize a timeline for this phase approach that makes sense given various needs but recognizing kind of the critical nature of this work. And then we could have a potential board vote on the framework and timeline on the 22nd. And then GMCB staff will certainly continue identifying resources for hospitals to support this work. The first time we were here talking about this framework there was grant funding offered through the Office of Rural Health. And so I think it would make sense to circle back and see what other kinds of grants may be made available to help support this work. And then, as I mentioned before we hope to incorporate lessons learned from the sustainability planning into the hospital budget process. And for 2022 certainly not this hospital budget process would be too quick. But and then hopefully we can implement and issue the framework. So I'll touch briefly on the regulatory integration piece. So the Vermont AllPair model offers an opportunity for providers to receive stable funding stream in exchange for providing high quality value-based care which we've been talking a lot about today through the sustainability planning. And under the model the ACO participates in a two-sided risk arrangement of CMS in exchange for these all-inclusive population-based payments. So they're fixed payments that are at this time reconciled against fee-for-service at year end. So this risk and the potential for shared savings and losses is then passed on to providers, mainly hospitals, to incentivize care delivery reform. And with the eruption of COVID-19 this has exacerbated challenges to providers sustainability and the ability of certain providers to accept this risk and continue their participation in the model. Much less join the model for the first time or join the Medicare program if you're already participating in some other programs. And for this reason, GMCB staff have asked CMS whether they would be willing to contemplate a reduction to the risk corridor for FY 21 so we can continue to build on this work. So at the same time, providers, stakeholders and legislators have voiced a desire to increase the opportunity for truly stable and predictable funding streams. So thinking about true capitation in the Medicare program, thinking about global budgets and any other mechanism we can to provide opportunities for providers to access a more stable fund flow, particularly in light of potential resurgence or new pandemics. And we want to continue the state's investment in population health because we think that will make for mentors healthier and have better lives. So the plan here would be for GMCB staff to engage with stakeholders and continue information gathering on providers' abilities to accommodate risk in 2021 and beyond. And then kind of think about collectively what a hypothetical capitated model could look like or global budgets or whatever that is, but to think about those stable funding streams and try to understand what our provider needs are on that front. And then I think staff would then come to the board and present findings on what we learned from those conversations. So I'll pause there for questions and public comments. Okay, first we'll open it up to the board for questions. I see a hand up, Tom. Let me make sure my mic is on. So I don't have a... I mean, it sounds like a very elaborate and thorough process that you laid out to take a really careful and thorough look at hospitals and hospital operations, et cetera. But there's a piece of me that also says, is there or should there be any overlap between this effort and the price variation study that the A team is doing? Because you look at insurance with major payer. In 2019, it was $1.4 billion of money that came into the system. And through the insurer, part of it to hospitals and part of it into hospital operating margins. And over that five year period, I mean, it's a statistic that still captures me in a way, is that 90% of all the operating margin among hospitals went to the UVM Medical Center. And so that raises a question to me, is that a rational outcome of the system or is it something else? Because the cost shift and payer mix have a lot to do with sustainability. And so if we're just looking inside the walls of the hospital for efficiencies, and certainly I'm sure we'll find some, but we're not doing it in the context of a payer mix, which clearly evidences some irrationality in it in terms of the smaller hospitals having negative operating margins and a substantial amount of the operating margin going to one entity. And we have this price variation study that's kind of looking at, where there might be inefficiencies in terms of services. The thought crosses my mind that maybe the scope of this over time, I mean, clearly you want to get through the hospital piece, but maybe the scope of this over time should take a look at the three major funding sources and how that money flows through the system. And is it doing it in a way where it's marrying up with the most efficient providers of the services at the provider level? Yeah, thank you. I reckon, yeah. So I think payer mix is certainly something that you will see throughout this framework. But I mean, as you said, I think we need to kind of not put the cart before the horses and get through the hospital piece first. And then the board is certainly open to regulatory integration. I think the board just launched this white paper, but I imagine there will be follow-ons to that work as time goes on. So certainly an opportunity to write down. I've noted it. Thank you, Tom. Tom, just remember to remove your hand. Other questions from the board? Robin. Thank you, Elena. I'm interested in seeing what kind of public comment we get today and coming back, particularly around the timeline because there is a lot going on. I like the idea of trying to work through how the sustainability issues that even pre-COVID were threatening our hospitals could be incorporated into a next round of all-pair model design, which seems still like that's very far away, but it's actually not given that we have some requirements in the decision, I mean, in the agreement to request the next round as a state chose to do so in the not too far future. So I like that aspect of it. I do worry that I think the hard part for me to balance about this effort is that given the situation that we are in with COVID and the sustainability issues, time is of the essence. But this is also a tough time for hospitals to engage in a thoughtful outside of the box process, which is I think what we're hoping they will do. I don't think what, I'll speak for myself. Like I'm hoping what we don't get back in response to this is what I would expect from sort of in the box consulting exercise such as well, you should cut the low margin services and put more energy into elected surgeries because that's where you're making money, right? I think what we're hoping for is a process where hospitals are thinking a little more outside the box in terms of really how do we creatively try to move forward with a sustainable model? And that necessarily is the harder exercise and requires more time. So I don't know what the timeline, I mean, we're really like stuck between a rock and a hard place on the timeline. So I don't know what the right answer is there, but I just thought I would express my view on that. Thank you. Jess, you're on mute, Jess. We all do that.  So first of all, I wanna thank Patrick, the presentation Patrick that you gave was really thorough and very eye-opening and appreciated it very much. And also Elena, I appreciated your presentation very much and all the hard work that you and Patrick and Jeff have been doing on these planning exercises. Pulling both presentations together, I would say the national statistics on rural hospital closures are pretty sobering and Vermont statistics on margins are also very troubling and there were headwinds before COVID and obviously the recent pandemic only accentuated how vulnerable our healthcare system is, right? So and I don't foresee it necessarily getting better if our population continues to decline and fixed costs are growing largely because technology costs are growing. We're not gonna, this is not something we can just get out of quickly. So I think this is a step forward. Again, I welcome and look forward to public comment and I'm assuming that this is work I would hope every hospital is already doing, particularly knowing that we're going into a value-based world and hospitals are gonna be accountable for cost and quality for the services that they offer. And that's beyond the state's healthcare reform that's nationally driven Medicare reform efforts. So I think this is work that hopefully more or less hospitals are doing and having a consistent framework will provide us with a more holistic view of the delivery system than the challenges to sustainability in this value-based world. So my hope is that, you know, I think the timeline we need to think about but the more information that we have prior to March when we have to develop budgets for next year will be really helpful because I think it would allow us to do more nuanced hospital budget guidance. I think now we have a kind of a blunt instrument and a one-size-fits-all approach. If we have a better understanding of some of the challenges to sustainably delivering care, you know, high-quality care at low cost, we may be able to develop a more nuanced budget guidance approach that reflects the challenges inherent in all of our communities. And it would help us ensure that hospitals have adequate resources to deliver essential services as defined by the AHA. And that the other services that they're delivering are being delivered at low cost and high quality, which they're going to be accountable for in this value-based world. And again, also the timing is also important in the sense that we are trying to think about, you know, refinements to the all-payer model and look at the next version look-like, lessons that we've learned, and to the extent that we want to include sustainability of our hospital system as a goal, I think we do, this will be more fodder for that conversation in our negotiations with the federal government. If we really want to think about, we want to keep our hospitals sustainable and these are some of the challenges they face. So on all of those fronts, I think this framework is really helpful, important. I think we can, you know, improve our decision-making and it's important to know what hospitals can do. And also I like the questions around, what can other stakeholders do to help the sustainability? So, thank you. Okay, Maureen. I just want to thank the team for all the hard work that went into this. I too am really going to refrain until we get some public comment, but I'm just going to put out a couple things that maybe of concern, which is, you know, really the ability of the smaller hospitals to provide information on the margin, both on a contribution and on a fully loaded. And you know, one thing I'll point to is when we just looked through the hospital presentation where we saw a significant decline to budget on top line, expenses were right on to budget, you know, plus and minus, et cetera. But the point really showing how there is such a fixed base of costs. So when you start to allocate those to services, that can become difficult. So be interested in also the consistency of what each of the hospitals will be able to deliver and will their process be the same, I think is going to be, you know, really important. And just something that Robin touched on briefly, but it's not like we want the, you know, as we said, like the surgeries to be driving this, it's probably what would come out of this would be the opposite. However, if we look at the essential services, that may not be where hospitals are making money and they are making money on the other side, which keeps them afloat.  So I think there's something that definitely needs to be done. I think that, you know, we're seeing hospitals that are going out of business, but I'm not sure just getting this information, right, is going to be the aha solution. We're going to have to really be all working together collaboratively with the system. And I think in some of the cases we're asking hospitals to come up with the solutions when they may not have the capabilities to do that. If we're saying cut a service and then say, find out where it can go, they might say, like, how am I going to do that? You know, I can't necessarily work on all the transportation and everything, but if we're working across the whole system to try to see where things should be done, and, you know, in certain places and not in others, you know, we're going to have to figure out how that works out. So, interesting to see what the comments we're going to get, but a lot of hard work and certainly something that we do need to make progress on. Yeah, thank you. So before we go to public comment, if the two board members could just lower their hands, great, thank you. So at this point, we're going to open it up to public comment. So Mike Fisher. It worked. Thank you. Thank you, Patrick and Elena, that I agree, interesting presentation, great presentation. My question is, Kevin, I wonder whether Patrick would have a perspective. Patrick's presentation was before the 275 million more that's being distributed to providers. I understand that's going to more than hospital providers, but I would presume some of it's going to hospital providers. And I wonder whether he would have some insights as to how that might play out on the presentation that he provided. And then also, whether any of those monies can reasonably be tracked to reduce, to improve access for consumers. So unfortunately, Mike, the answers to both your questions are going to depend on what AHS does as they dole out the money. And so we're going to track it no matter what to make sure that in the old Seinfeld episode, there's no double dipping, but I guess it's way too early for Patrick to be able to answer the question because he just doesn't know how that pie is going to be doled out. Okay. We will be following it intently. And that's what's going to be tricky because these answers are going to come at the tail end of the budget process. But I think your comments about the benefits to consumers really should be directed to Secretary Smith, Mike. Okay, thank you. Okay, Mort Wasserman. All right, thanks. Those presentations were great. And forgive me if I sound like I'm pontificating, but I recall that two statements that strike me as very important. One is Paul Batalden, quality improvement expert, once said that every system is perfectly designed to get the results that it achieves. And this system, our whole hospital system and its primary care system and the supportive agencies is absolutely nuts. So, okay, let's just put that aside because most people recognize that there's room for improvement. The second is one of my mentors, Paul Young, used to say kind of exaggerating it that every hospital admission was a failure of primary care. Now that was an overstatement because it's a failure of social support systems as well. And of course some people need to be in the hospital but putting that aside and hearing in Elaine's excellent presentation the nod to primary care, but it's a nod to primary care from the hospital systems when in fact, a lot of the hospital systems aren't providing primary care and a lot of the hospital systems, some people, primary care people especially would advocate that everybody would be better off if the hospital systems weren't the direct providers of primary care. So, my comment is simply that there needs to be a very structured process perhaps for engaging the primary care community, both those participating in the ACO but also those who ought to be attracted into participating in the ACO and engaging them and not relying on the hospital systems to engage the primary care providers and practices and clinics and FQHCs that happen to be providing the primary care within their service area. Thank you more. Kevin, would you mind if I just make a comment on Mort's comment because I think it raises a really interesting, challenging issue for us in particular. Go ahead. All right, thank you Mort. I think that's an incredibly important point that you've made and I think it also highlights one of the challenges we have as a regulatory board engaging in this exercise from where we sit, which is we don't regulate the vast majority of the healthcare system, we regulate hospitals and their associated providers. And so ideally, I think if one were to engage in a resource allocation process across the state, one would want to do that on a health system basis as a whole, but we really from where we sit don't have the authority through our legal authority really to do that. So I just wanted to react because I don't disagree at all with what you were saying but I think it is also a little bit above and beyond what we have the ability to do. We can certainly, you know, we have a primary care advisory process. We always welcome public comment from anyone, regardless of whether it's within our authority or not. But I think it's also important for us to be really clear what we have the legal ability to manage and do because oftentimes there's this expectation that the legislature has endowed us with sort of never ending authority and ability, which is just really not true. And so just for myself, I like to be really clear about where our authority stops and ends just because I don't want to over promise anyone about what we're able to pull off. But thank you, that was a really important comment. Sir, just a comment to reply. I think in the short run, the point is well taken but in the long run, it needs to be fixed. So I can't believe that the Green Mountain Care Board doesn't have something to do with fixing this project, problem, excuse me, in terms of advising the legislature in times of engaging the primary care community, advocacy of some sort. I realize you're not an advocacy organization but there's a kind of advocacy that can be done through education. And in fact, the process that Elena and Patrick have outlined is a form of education. So maybe that's being one of the results. Thanks. Thank you, Mort. Jeff Thiemann. Thank you, Mr. Chair. First, I want to begin by saying that, as we've said on numerous occasions before from the hospital association that we agree on the need for sustainability planning. We've said that in formal correspondence with you and in conversations with the board publicly and in person. And clearly we support the need and the effort to keep our hospitals strong and healthy and able to continue effectively serving their communities. I think I'll just begin my remarks by sort of reacting to Elena a little bit. She started by saying, this is a really big lift. I could not agree more. And then she said, it's the right time and the right level of detail and I could not disagree more. Unfortunately, this proposal and framework is poorly timed and extremely onerous. It is an entirely new body of work that appears to have as a primary goal cutting the healthcare services that are available in our communities. Meanwhile, from a timing standpoint, it doesn't seem like we need to be reminded but maybe we do that we're still dealing with COVID in a very real and daily kind of way. Not just messy and uncertain budgets which we've heard a little bit about today but also ongoing PPE and supply chain concerns, data reporting obligations to the state and the federal government including a brand new one that was just added yesterday and involves a lot of effort, testing supply shortages, travel policy problems that lead to staffing challenges for our organizations, students coming back in the fall with uncertain results and the prediction that the winter wave of COVID is almost certain to be worse and then a huge continued uncertainty around financials, medical services, supplies and what the federal government is gonna do just to name a few. So even if we were not in this environment, this proposed regulatory scheme represents as we have said before, even before we knew what it looked like now, we said it represented enormous government overreach without clear benefit and I continue to stand by that. What's been proposed and shared today is intricate and long and cumbersome. It amounts to an entire regulatory requirement in and of itself that rivals if not exceeds the budget process we already have in place. Last year we discussed at length, we had two very long in-person meetings where feedback was allegedly collected to inform this process. In those meetings we described and also in corollary correspondence that there are other ways at this sustainability conversation, including to assess hospitals financial health using ratios widely accepted and objective measures that capture each organization's financial strength and stability, the same ratios that we know inform bond ratings. And to reduce the administrative burden as a couple of you said is important by clarifying budget guidance questions to achieve the goals of sustainability planning. So in other words, we can do this within the process and structure that we already have. So it was just terribly disappointing that none of that input was heard or apparently included or reflected. And instead we're now evaluating a framework that is not tenable or reasonable or productive. And I wanna clarify a couple of things too that were said in the presentation. Elena said that Vaas supported doing this for all hospitals. That is flatly wrong. What I said and what Vaas has said on many occasions is that sustainability planning should involve all hospitals, but not this version of it. And it certainly was made to sound like we endorsed this complex framework as the way to do this, not at all true. We said it should be part of the budget process. And it was said several times that we endorsed this framework and we do not as you can tell from my remarks. It's also really disappointing and super challenging to receive this enormous complex framework last night and have less than 24 hours to evaluate it before this important discussion. In our view, this exercise should be about making sure that hospitals have the financial resources and wherewithal and planning tools to stay strong and to serve their communities. The Green Mountain Care Board already has the tools in place to make this happen. And in fact, a structure and a process that enables it. We don't need a new regulatory process which is what we're talking about now in the state that already has the most onerous and elaborate regulation of hospitals in the entire country. So our recommendation was to combine this with the budget process, which seems so much more logical than creating a parallel and overly burdensome regulatory scheme which is what we're looking at. Just a couple last points which is that in the COVID environment our visibility is so limited. Look at the state. The state is not even doing a year long budget because visibility is so limited. That is certainly true in the healthcare space if not much more so. Sustainability should involve a dialogue on both cost and fair reimbursement, on a fair payment model that's attractive to providers and on making sure that as we operate our businesses and serve our communities, our medical inflation and cost of maintaining vital infrastructure is managed appropriately. So what I would recommend given our reaction so far is that this whole entire process be put off until at least November that we revisit it at that point and talk about what next steps might look like and what a different framework could look like. And short of that, we will be providing additional specific comments on each of the components of this framework. But as it stands, we object to it and we'll talk to you further about that as we move forward. Thanks. Thank you, Jeff. Mark Stanislaus? Hi, Mark Stanislaus from the University of Vermont Health Network. So I mean, well, so first of all, thank you for a very detailed presentation. I mean, it was clear to see the work, the effort and the thought that we went into it. And it's also appreciative that you're trying to find data from other sources to lower the burden on the hospitals as much as possible. But I just have to reiterate what Jeff said, that this is a lot of work. And yes, I think there's value through this effort, but I think we just need to think about how we can go through mining that value in a different manner. And without getting into the specifics, I'm not even sure it's possible to provide all of this information that was shared.  I mean, I would throw out there if we are really serious as a group on how to go about financial sustainability planning and discussions in say an effective way with the goal of finding solutions. I think one of our finding shared solutions, one of the first steps is to do a capacity study, okay? Of what our population can support from services because I don't know how you get to financial sustainability without knowing, we know what the appropriate footprint should be. We have 14 different hospitals in this state. Who knows if 14 are needed, okay? Because if 14 aren't needed, then the financial sustainability stuff. I mean, this is basic white paper stuff. You know, you need to start there to put that in comparison. And then, you know, I would just throw out, if you know, this is about finding solutions and when it comes to finding solutions, you need to understand all of the drivers and put the full picture together. But as the presentation, as I interpreted it, okay? You know, this is what the hospitals can do for their financial sustainability, but I would add there, you know, we need to put how the Green Mountain Care Board, the commercial payers and the hospitals can partner together to find that pathway. It is really the coordination at a minimum of all three of those. And you know, I am sure there's, you know, more. And as far as the current downward, you know, trend, I think it was on slide seven, you know, I think it's important to have a sustainable system. You need to have commercial rate increases that fund inflation. And what we saw partly on that slide seven, where the hospitals own part of the responsibility to effectively manage expenses, part of that downward trend was commercial rates applied to hospitals did not keep pace with inflation. And the compounding impact in future years of that is significant. And that's why I think we saw some of going into the pre-COVID poor financial performance. We can't undo that overnight, but we need to be willing to put those components on the table. And you know, the best I can say is the University of Vermont Health Network meets three times a year with three rating agencies, three different ones that specialize in healthcare, speak to hospitals all across the nation. And if there isn't a better gauge to understand what financial sustainability is taking a look at those rating reports and they even call out the lack of commercial rate increases also. Okay, and then I don't think we can overlook the burden that the cost shift has put on hospitals over this time period that has also added to that downward, we know margin trend. So, you know, if this is about finding solutions in a pathway forward, you know, we need to be willing to put those discussion comments on the table at the right time.  But, you know, when we're closing budgets, we're figuring out how to bring employees back, you know, back to work, you know, what we're being told is that there could be another wave of COVID in the fall, early winter. So, you know, keep in mind that it does make sense to make progress on this too. So, you know, we just need to balance that together. I mean, so thank you for this opportunity to let us share my comments. Thank you, Mark. Jeff, do you have another comment or you just didn't take your hand down? No, sir. I'm not used to my Chris, whatever this is. So I didn't know how to do that. Thank you, sorry. You just have to click on that hand. That's all. Got it. We're all struggling to get used to ever-changing technologies. Is there other public comment? Yes, hi, Kevin. This is Kathy Mahoney. In listening to all of the speakers on this issue, first of all, I agree with thanking everybody for the presentations. Both of them, there's obviously an awful lot of detailed work that went into them and I appreciate that. The second presentation, this was really comprehensive and as I listened to it, my reaction to it was that it sounds like a plan under ideal circumstances and it all makes sense and the questions need to be answered in order to get us where we need to be, but I don't know that we're there at this point that we could actually follow such detail. So then I began to think more about it as really a change management question because I think what everybody is really trying to get to is where do we need to be in the end to have sustainable healthcare and affordable safe healthcare in Vermont? And I am relatively new to the group here and so I forgive me please if I ask a question to which there perhaps is already an answer. But when I go back to change management philosophy, I think of assessment, how do we decide where we are sort of our present state of affairs? And some of the questions ask those kinds of questions. Do we have the capacity at all the different hospitals that we think we have? Do we have the financial, people with the financial chops, people with the reporting skills? Do we have people who can collect the data? All of those things are necessary to make the actions outlined in this comprehensive plan possible. And I just don't know if every hospital does. I think I have a better handle on whether private practices and private practitioners do because that's a hat I used to wear. And it strikes me as unlikely that the majority of smaller groups and smaller practices would be able to contribute quality information to the conversation around assessment. So I'm really not sure that we're there enough and perhaps the focus should be on following maybe a change management principle of a formal assessment. The other question I have or the other concern I have about this is that when we do change management, one of the things that is very important and I think somebody said this, there might have been Jeff, is that we need to have a standard set of questions and vet that process so that we're sure that the data and the information or the answers we get to these questions from hospital A, hospital B, practice X, practice Y actually are consistent across the board. Otherwise the data that we get to make these important decisions about sustainability, the data will be very valid. So I think that it seems a little early and I also am concerned about the impact of doing this right now with COVID because so many facilities are short on simply administrative staff. Many administrative support staff, secretaries have been furloughed, many nurses and many other quality data folks have been furloughed and we're behind on reports. I just have a hard time that's imagining how we'd actually pull this off. Thank you, Kathy. Other public comment? So not hearing any, I just want to state that given the feedback that we received the date, it's unlikely that there'll be a vote today. And I think it's important that we work constructively with the stakeholders to make sure that the timeline works for everyone. So Jeff, what I would be asking you for is some real meaningful feedback of what can be done and under what timelines and we'll come back to this topic again next week. But if you could get that to us before next week, that would be much better so that we can plan accordingly. Is that okay, Jeff? Yes, I will plan to do that, Kevin. Thank you. Okay, and Robin. Kevin, can I just ask a question? I didn't think we had a Wednesday board meeting next week because of the rate hearings. Oh, you might be right.  Yep, no, no board meeting next Wednesday. We certainly can take anything up after their rate review hearings, their long days. And we also have the public forum where we'll all be together. But we may wanna, you know, we can get the feedback and then maybe the next week talk about it, Kevin. Yeah, I don't think there's any real problem with waiting till the 29th. Thank you. I don't need that. I just wanted to bring it up since we had been saying acting as though we might be acting on something on the 22nd and it gives a little more time. Yeah. Is that okay with the full board? People could just nod or shake. Yes, and I also think it gives boss more time to prepare something about what they'll be able to do. Thank you, Morgan. You're welcome, Jeff. Okay, so with that, we're gonna move on to the next item on the agenda, which is a legislative update. And I'm gonna turn it over to Christina and Jean whenever you're ready. I will share my screen, so just give me one second. Okay, can everyone see that? We can. Okay, perfect. So Christina McLaughlin, health policy analyst with Green Mountain Care Board. And this will be hopefully a brief presentation, just providing an overview of the last handful of months of the legislative session. And then I will turn it over to Jean Stetter, our administrative services director to review the Green Mountain Care Board budget. So first and foremost, there were a few big bills signed by the governor, a couple fairly recently. The bills listed here were signed between the end of March and early July of 2020 and they include Act 91, an act relating to Vermont's response to COVID-19, Act 136, an act relating to healthcare and human services related appropriations from the Coronavirus Relief Fund, an Act 140, an act relating to miscellaneous healthcare provisions. I wanna just provide an overview for Act 91. The act provides administrative and provider flexibility, including the bullets listed below, which include increases flexibility for AHS to address COVID-19, allows the Green Mountain Care Board to waive or permit variances from laws, guidance, and standards related to hospital budget, CON, health insurance rate review and ACO budget review for up to six months after the COVID-19 emergency. It directs DFR to consider adopting emergency rules to expand health insurance coverage and to waive or limit cost sharing requirements and expand patient access to and provide a reimbursement for healthcare services delivered through telehealth, audio only and other telecommunication services, offers changes to prescription drug coverage requirements and increases healthcare professional licensing flexibility and expands telehealth insurance coverage. So the board is mentioned in section five of Act 91. Essentially the board is allowed to waive or permit variances from state laws, guidance, and standards with respect to the regulatory activities listed to the extent permitted under federal law to prioritize and maximize direct patient care, safeguard stability of providers and allow for orderly regulatory processes that are responsive to needs related to COVID-19. The board has implemented Act 91 in many ways and to name a few, the board has closely monitored hospital financial health and is, as we saw today, continuing internal development of the hospital sustainability planning, streamlined CON processes for new healthcare projects that support the state's ability to respond to COVID, requested flexibility and additional funded to be directed to providers for Vermont COVID that relates to our all-payer model. And in regard to the ACO adjusted budget orders in response to COVID-19. There are many, many more, but I just, sake of time, I didn't wanna list off too many. Moving to Act 136, the act contains a total of 326 million allocated to healthcare and human services and just a high-level overview, 275 million of that money is allocated to grants for eligible healthcare providers, including hospitals, independent doctors, mental health providers, dentists, rural health clinics, FQHCs, labs, the remaining funds are for childcare, food assistance and other services. Act 140, I'll switch to that now. A quick overview is the act addresses mental health, hospital budget review, expansion of VFARM coverage and the review and modification of prior authorization requirements. There are many sections of Act 140 that directly relate to the Green Mountain Care Board and I'm going to outline those in the next slides. So section one of Act 140 is amended to direct the board to collect and review data from each community hospital. Sorry, each community mental health and development and disability agency designated by the commissioner of mental health or disabilities, aging and independent living, which may include scope of service, volume, utilization, discharges, payer mix, quality coordination and other aspects of the healthcare system and financial condition, including solvency. The Green Mountain Care Board is required to have processes appropriate to the designated and specialized services agencies scale and their role in Vermont's healthcare system. And they must consider ways in which the psychiatric hospitals can be integrated into system-wide payment and delivery system reform. So moving on to section three of Act 140, which pertains to Brattleboro Retreat, it directs that any hospital whose budget newly comes under the board's review as a result of the amendments to 18 VSA section 94-51 made by section two, the board may increase the scope of the budget review process for the hospital gradually, provided the board conducts a full review of the hospital's proposed budget no later than the budget for FY 2024. In developing its processes for transitioning to a full review, the board shall collaborate with the hospital and AHS to prevent duplication of efforts, reporting requirements, the board and AHS shall determine which documents submitted by the hospital to AHS are appropriate to share with the board and determining whether and to what extent to exercise discretion the board must consider existing fiscal oversight of the hospital by AHS and fiscal pressures on the hospital as a result of COVID-19. Moving on to slide nine, Act 140 has a lot of language relating to prior authorization and to be starting off in section eight, 18 VSA section 94-18B is amended to require health plans to annually review the list of medical procedures and medical tests for which it requires prior off, at least annually and shall determine the prior authorization requirement for those procedures and tests for which a requirement is no longer justified or for which requests are routinely approved with frequency as to demonstrate the prior off does not promote healthcare quality or reduced spending to a degree sufficient to justify the administrative costs to the plan. And it is amended to attest to the DFR and on care board annually or on annually or before September 15th that it has completed the review and appropriate elimination of prior off requirements as required by the subdivision one above. Again, more prior off in section nine of Act 140 it also relates to electronic health records. DFR is required to consult with the health insurance and healthcare provider associations to report opportunities to increase the use of real time decision support tools embedded in EHRs to complete prior authorization requests for imaging and pharmacy services including options that minimize costs for healthcare providers and insurers. This report is due honor before January 15th, 2022 to the Green Mound Care Board and the committees that are listed below. Again, more prior authorization and this relates to the all-pair model. The board in consultation with Diva certified ACOs payers participating in the all-pair ACO model healthcare providers and other interested stakeholders shall evaluate opportunities for and obstacles to aligning and reducing prior authorization requirements under the all-pair ACO model as incentive to increase scale and opportunities to waive additional Medicare administrative requirements in the future. There's a report due honor before January 15th, 2022 and the board shall submit the results of its evaluation to the health care committees. Act 140 section 11 touches on prior authorization and gold carding honor before January 15th, 2022 the health insurers with more than 1,000 covered lives in Vermont for major medical shall implement a pilot program that automatically exempts from or streamline certain prior auth requirements for a subset of participating healthcare providers, which include primary care providers. The insurers shall make available electronically including on a publicly available website details about its prior auth exemption or streamlining program, including criteria that is outlined in section 11. I did not include the criteria. It was a long list just to save space and time. The report is due honor before January 15th, 2023 and each insurer is required to implement a pilot program shall report to the house committee on healthcare and Senate committees on health and welfare and finance and to the Green Mountain Care Board. And they mustn't leave the four items that are listed below. So prior auth and provider exemptions section 12 act 140 states the honorable forward December 30th, 2021 diva shall provide findings and recommendations to the board, house committee on healthcare, Senate committees on health and welfare and on finance regarding clinical prior auth requirements in the Vermont Medicaid program, including on the description evaluation of prior auth waiver pilot program for Medicaid beneficiary to the Vermont Medicaid next generation ACO model. The service of which Vermont Medicaid requires prior auth included denial rate for prior auth requests and the potential harm and absence of prior auth requirements based on the information pursuant to subdivision A of the subdivision two the services for which the department would consider waiving the prior auth requirement and exempting from prior authorization requirements whose healthcare professionals whose prior auth those healthcare professionals whose prior authorization requests are routinely granted. And so continuing with provider exemptions the results of the department's current efforts to engage with healthcare providers and Medicaid beneficiaries to determine the burdens and consequences of the Medicaid prior authorization requirements and those providers and beneficiaries recommendations for modifications to those requirements. Potential to implement systems that would streamline prior auth processes for the services which would be appropriate with a focus on reducing the burdens on providers, patients and the department for for which the state and federal approvals wouldn't be needed in order to make proposed changes to the Medicaid prior auth requirements. And finally five the potential for aligning prior auth requirements across payers. Act 140 also includes extensions relating to Act 91. Act 91 extends several, I'm sorry 140 extends several positions in Act 91 beyond March 31st, 2020, including the following teams out of state licensed healthcare professionals licensed in Vermont. We have certain telehealth requirements during the state of emergency. Allows retired healthcare professionals to practice under specific requirements. And Act 140 also allows the department of financial regulation, emergency rules, rulemaking and extensions 30-2021. I'll move to the bills that the board has some interest in and we're following COVID-19, obviously, given the pandemic, everything else was sort of put on pause to focus on COVID-19 legislation. So I'll just read through these bills that we believe will be taken up in August when they come back to session. And then I will turn over to Jean. So one of the big funding house bills is H607 and act relating to increasing the supply of primary care providers in Vermont. As noted at the bottom, this is passed in the house and is now referred to Senate Health and Welfare. In the current version, the bill would direct the healthcare, the director of healthcare reform to maintain a current healthcare workforce development strategic plan with the help of an advisory group to continue efforts to ensure that Vermont has the healthcare workforce necessary to provide care to all Vermont residents. A draft of the plan must be submitted for review and approval to the board by December 1st, 2020 and the board shall review and approve the plan within 30 days. On or before January 15th, 2021, the director will provide the workforce strategic plan to the legislature. So also direct Steve to collaborate with the office of primary care and area health education centers at UVM College of Medicine to establish rural primary care position scholarship program and appropriates money to the Vermont Department of Health to additional scholarships for nursing students through the healthcare educational loan repayment fund. Other big bill is H795 an act relating to increasing hospital price transparency. This also has passed in the house and the bill is now committed to the committee on health and welfare. It would direct the board with honor before February 1st, 2021 to report its progress to healthcare committees and Senate finance and developing and implementing a public interactive web-based price transparency dashboard for more use by healthcare consumers including the results of the board's efforts to validate B-Cures data through the comparison with hospital discharge data and information from health insurance. The board shall develop and maintain a public dashboard that allows consumers to compare healthcare prices for certain services across the state. The dashboard shall be accessible on the statewide comparative hospital quality report published by the commissioner of health. The board is required to update the information at least annually and honor before February 1st, 2022. The board shall provide a demonstration of the dashboard to the house committee on healthcare and Senate committees on health and welfare and finance. This bill will most likely be taken up in August, but so who knows if dates will change, but we shall see. Moving on to Senate bills that are pending starting with S-202 and act relating to limiting the copayment amount for chiropractic services and certain health insurance plans. This would obviously limit copay amount for chiro services in silver and bronze level, qualified and reflective health benefit plans to no more than 125% of the amount of the copay applicable to care services provided by a care provider under the same plan. Currently this bill is sitting in welfare is referred to them by Senate finance S-245 and act relating to eliminating cost sharing requirements for primary care. This would just have no cost sharing for preventative and primary care services. This bill very much as introduced a version and is currently in the Senate finance committee. S-290 and act relating to healthcare reform implementation. This is quite a big bill. It would create additional reporting certification and budget requirements for ACOs, direct hospitals to report certain rate increases to the board, impose new requirements on contracting between health plans and providers and the board's membership must include a healthcare professional, require the board to begin exercising its great setting authority and establish site neutral reimbursement amounts and direct the board to review and approve contracts between health plans and providers. The bill would also impose limits on health insurance rate increases attributable to administrative expenses and require the agency of human services to report on two-year ACO budget and reporting cycles and on the likely effects of attributing or not attributing state employees and public school employees to ACO. This bill is still sitting in the Senate Health and Welfare as of March 9th. There is a draft 1.1. The board along with a long list of other folks have provided testimony and recommended changes to this bill pre-COVID. This will most likely be taken up again when they meet back up, but I kind of assume it will change form at least one more time just because it is a big bill and there has been a lot of testimony on it. Two more pending Senate bills includes S296 and act relating to limiting out-of-pocket expenses and prescription insulin prices. This would limit the beneficiaries total out-of-pocket responsibility for insulin medication to not more than $100 per day supply. This is passed in the Senate and has been referred to the House Committee on Healthcare. So this will likely also be taken up in August S309 and act relating to limitations on healthcare contract provisions and surprise medical bills. And this would bring certain provisions and contracts between health insurers and healthcare providers and limit out-of-network providers at in-network facilities. So that is the high level overview of the legislative bills. So I will turn it over to Jean unless you wanna pause now for questions, but Jean only has a couple of slides. So if she's ready to present, I'll just pass it over to her. Yeah, we'll take the questions afterwards. Okay, sounds good. Jean, are you on? I am on. Thank you very much, Christina, for doing that. So what I wanted to highlight is that, as you all know, we're an unusual place this year. It's atypical for the state not to have an approved budget for the fiscal year that we're in. We do have an approved budget for the first quarter of fiscal year 21. And that is a straight 25% of the budget that had been submitted. So we do have spending authority. All the agencies in the state have spending authority for that based on a straight 25% allocation. But what we're working on now and we're working to submit is a FY21 restatement budget. So what that looks like is they've currently given agencies and departments a goal of a 5% general fund cut. And so we are working on preparing that now. It could be that what the governor submits to the legislature, the legislature comes back on August 25th. He plans to submit his official budget to them about a week prior to that. It could be that the numbers will change. We won't get our final targets until then. But that's what we're currently working under. And you can see that indicated in our total appropriation chart there. Now, Christina, if you'd be willing to change to the next slide, what that shows is for the Green Mountain Care Board because our funds are comprised of general fund and billback fund at 4060. If we, you can see that if we have a 5% cut reduction in our general fund, we will have a corresponding 5% reduction in our billback fund. So that just shows how it translates across because of a statutory 4060 split. So that's what I have. We don't have final numbers, but we're working towards it and the legislature will be back on or around August 25th to take it up. Thank you. We'll start with the question. Well, you too must have done a good job because I'm not asking questions. So at this point, it's going to open it up to public comment. Is there any public comment? Again, I don't hear anything. The only thing I hear is either somebody doing the dishes or taking apart or putting together a piece of something, but that's been throughout the last hour or so. So with that, is there any old business to come before the board? Hearing none, is there any new business to come before the board? Hearing none, is there a motion to adjourn? So moved. So moved. Second. It's been moved and seconded to adjourn. All those in favor signify by saying aye. Aye. Aye. Opposed? Thank you everyone and have a great rest of the day.