Chair Mullen and members of the Green Mountain Care Board. I'm John Bromstead, CEO of the UBM Health Network. You probably know that because I've been here a couple of times before. I do wanna start by thanking you for the opportunity to present our 2022 budget. Up to imagine that it's a 2022 budget, but it is. And I also wanna take the opportunity to thank the staff, both at the Green Mountain Care Board and our staff for taking the time to respectfully have back and forth up to this point to question each other, to begin to come to a mutual understanding of what's a very complex budget produced during and covering a very, very complex time in our history. And our aim through the presentation this morning and likely answering questions late this morning and this afternoon is to provide any further clarity that you on the Green Mountain Care Board need to facilitate your decisions. We'll take the next slide, John. So here's the team that's available today. Those folks have sworn in. I will take a second to brag on the team because it's a spectacular team that has helped guide the path through some incredibly difficult and tumultuous times to make sure that Vermonters and folks in Northern New York continue to get the services they need. All of us on the team are well-known to the board, maybe with a couple of exceptions on the finance team which has had a makeover over the past year. Rick Vincent does have a track record but has moved up to being CFO of the entire network after years of training in our network. Judy Peek Lee has joined us over the past year and is the CFO of the Medical Center in Burlington, Kim Patnode at Center Vermont, and Scott Como, some of you may know Scott at Porter Medical Center. I would like to call out that we do, I believe have some of our trustees from around the network that are listening in today and I wanna thank them for their time. I believe we have Maureen McLaughlin, John Dwyer, Tom Little, many of you may know Tom, and Collins, Pat Dunn-Hauer, Allie Stickney who actually is the incoming board in January will be the board chair of the UVM Health Network and Allie Richards. So next slide. What we intend to cover today, I'll run through this quickly and at a high level, our mission, vision and major initiatives that support that vision and that our mission and vision have not changed. Quickly who we are and where we are in our integration as an integrated health system serving the region. And I'll take those two pieces over the next 15 plus minutes. Then how we weathered the challenges of 20 and 21, and they have been many, many of those. I'll ask Al to speak about those. Our continued plan and march towards financial recovery and how we perform against external benchmarks. You know that I and our team always seek external validation to keep us on the straight and narrow. And we believe that that's important in this context as well. We'll go through some of those. Our net patient revenue growth compares to our population growth. In other words, how net patient revenue growth is a function of both expense growth, what we call expense inflation and population growth. Both of those factor in. And particularly because of the population growth piece, we must be measured and judged and evaluated on a per capita basis. To do otherwise, we'll continue the potential and actually the likelihood for significant untoward consequences. We'll take the opportunities through each of our presidents to talk about the challenges at our Vermont affiliate organizations and we'll summarize the budget. And again, the bottom five bullets will be covered by Al Gobey, who's our chief operating officer, chief financial officer, Rick Vincent and our presidents. And again, our CFOs at the entities will be available to answer questions. Next slide, Jen, please. So UBM Health Network, our entire reason for being is to assure access to high quality healthcare services for our region, Vermont and six counties of Northern New York. And we're here not just for today, but for the longterm. So we have to be sustainable and we have to provide those services at reasonable affordable costs. And obviously that reason for existence rolls off the tongue, you know, and we live every day how incredibly difficult it is to realize that. Next slide, please. Every year I present our mission and our vision. These have been durable over time, they have not changed. And we're a mission driven organization from the top down. And this can be seen in the persistence, the drive, the innovation that's been on display over the past months in meeting our mission as we've had obstacle after obstacle thrown in our path. And I believe being mission driven is the necessary ingredient to being resilient. And if there's one word that characterizes our workforce, our organization over the past two years, it's resilient. And so working together, we improve people's lives always a very collaborative, respectful model. Next slide. So who are we? The map hasn't changed, same geography. There are some updates here. Relative to other organizations in our region, I know we know that it's really difficult for folks outside of the organization, outside of our system to get their heads wrapped around our scale. And it's really difficult to translate that scale then to the accountability that comes with that scale. And that accountability for delivering services and the health of the region is born by every single person in the organization, not just the leadership. So a couple of examples of that scale, if you go from Center Vermont Medical Center to the East and you drive to Malone, New York, Elliside Medical Center to the Northwest, on a day like today, nice dry roads poking along, you make it in a little over three hours and there's a ferry ride in the middle. And when you do that drive, there's a huge expanses of rural real estate and that impacts everything that we do, our decision-making, how we deliver care and what's expected of us and we know that. A few of the factoids that are here were the same constellation of providers. Some of the statistics in 2019, which was the last semi-normal year, there is such a thing. We had more than 41,000 inpatient discharges and 1.3 million outpatient encounters. And not that many fewer if you jump up above that to 2020, which was a very bizarre year, almost the same amount. Also, we contract or employ, mostly employ, more than 1,400 physicians and almost 300 of those are primary care physicians. So, big scale, we absolutely understand that and particularly when you start talking dollars and cents, there's many zeros after the numbers. It's because of our size, but again, that translates into us knowing the accountabilities that come with that scope and scale. So next slide, Jen. So progress to date, we actually began our journey 10 years ago, October of 2011, with the formation of then Fletcher Allen Partners. Now, blissfully, a much better name, the UBM Health Network. And we started that journey with two core strategies, just two, becoming a tightly integrated delivery system to maintain access to high quality health services for the region and shifting to payment and delivery arrangements that reward high value care. We've made significant progress along this journey, but it's clearly far from over. Through the presentation, you'll get a lot more detail on what's on this slide and we're certainly open to questions on what we've accomplished and where we're going. But I'll just tick through some high level thoughts here. On network integration, we've lived through, as have all of us, we specifically have lived through an organizational stress test over the past two years. And if we had not been a highly integrated collective of healthcare organizations, I am absolutely certain that we would have lost one of those organizations, the way of Springfield or EJ Noble in Northern New York, if they had been standalone organizations. So we have seen the fruits of that integration through times that we certainly don't wanna repeat. Expense management, we're seeing the benefits of economies of scale and implementing systems and platforms across our network. And this is not just in supply chain. You'll note that the administrative expense from our shared service as a proportion of our revenue has gone from 13.7% in the 2021 budget to 13.4% in the 2022 budget. And certainly Rick Vincent can deconstruct that for you if you'd like. And care management, we're pushing hard on our provider side to make our care management consistent, well-functioning and well-resourced, good provider side care management is a prerequisite to high quality care. It's also a prerequisite to us taking financial risk. We will not repeat the foibles of the 1990s when providers took on financial risk, did not have all of the levers to pull on the care management side. That was disastrous. And so we're working hard to make sure that our care management processes are strong. The EHR installation and integration epic, hard to believe, but within a year of completing that, Vermont entities will be totally done with the implementation phase in November of this year and our New York entities will be completed in April of 2022. Value-based payments, you all are well aware of the progress that we've made and continue to make in the all-payer model space. Our latest payer partnership with MVP to launch a Medicare Advantage plan is very consistent with our core strategies. It's a step along the pathway of realizing those strategies. And this plan is very complementary with the all-payer model and is in no way in conflict with the all-payer model. As providers, we're taking accountability for a population to provide cost-effective, high-quality care. Access to care and workforce. These are both huge issues, huge issues that we're all grappling with. And unfortunately, there are no silver bullets. Everybody wants to say, if we just did this, everything would be okay. There's nothing that simple. There's lots of very complex factors to deal with and to address. Just one example, access to mental health services, which have been difficult since Irene, probably before Irene, but definitely since Irene. Now, every single point on the care continuum for mental health services is stressed beyond breaking. It really is a crisis in any way you define it. And we on the healthcare delivery system side can't and we won't run away from that problem. We're gonna run towards it. That and the other crises around workforce and the impacts of COVID and pent up demand on access in addition to the mental health really are difficult to deal with. We need to have that discussion together. We can't do it alone to address these issues. We have to have our budgets and the resources to address these issues. And we need timely, I would say as rapid as possible, approval of the certificates of need that we've put forward to have the facilities to attract the workforce and to meet the demands of our growing population. In academic integration, we've made great strides with the Larner College of Medicine, the UVM College of Nursing and Health Sciences, SUNY Plattsburg and other higher education organizations to help us on the workforce front and to provide access to clinical material for their learners. Next slide. Leading healthcare delivery and payment transition the past two years as I've said repeatedly have presented real challenges to achieving our goals. Al is gonna speak with some specificity to what we faced. Those challenges have also showed us that we're on the right track in our move towards value-based care and really has stiffened our spine that's created renewed resolve to continue down the path to really realize the benefits of that transformation. We're continuing to lead the region in healthcare delivery of high quality and affordable care. A few of the things are listed here on how we are doing that and how we propose to do that going into the future just to pick a couple to dive a little bit deeper on investing in our staff and facilities so we can recruit, retain and support a first rate workforce. I said that ties directly into our certificates of need also to our budgets. We've put in things like workday which provide a lot of support for our employees to be able to access issues that they may have. We've worked hard to make wages and benefits appropriate. We now are like many organizations moving into the non-traditional. How do we provide flexibility for our workforce to work from home, to have non-traditional work hours and work weeks and we're thinking out of the box as others are on how we can differentiate ourselves to recruit and retain and in many cases train our own healthcare providers of the future and you'll hear more about that in the coming months. Investing in Better Access to Mental Health Services I've already pushed on that one quite a bit. This is one of those issues that we can't succumb to just nibbling around the edges. We need to dive in and we need to finally push on this so that we can start approaching with a straight face that we're providing parity to those that have mental health needs. That means an inpatient site capacity on our Central Mont Campus. It means an emergency department redo at the UBM Medical Center and it means doubling and tripling down on the workforce needs. So in our communications of late, we've had a consistent theme. I'm sure you've noticed that you and the external world judge us based on well-established external benchmarks. And Rick's gonna show some of our recommendations. They were in the presentation. You've probably already looked at them. There certainly have been discussions between our staff and the Green Mountain Care Board staff. Excuse me on these recommendations. But I just wanna run through some high level measures to start with because we need to be cognizant and reminded of where we are with healthcare delivery in our state because that is a good news starting point. It doesn't mean that there isn't a lot to do, as I've said throughout the past few minutes, but we need to remember where we're starting from. So next slide, Jim. So this comes from the Dartmouth Atlas and you all know that the Dartmouth Atlas is a time-tested source of truth for healthcare utilization and cost. And the header says it all. Vermont is the lowest cost state in the nation for the Medicare program on a per capita basis. The lowest, not the fifth, not the 10th, not the middle. We are the lowest cost state in the nation for Medicare. And look at the legend there, we're almost $3,000 less than the national average on a per capita basis. So anything that we're doing is improving on best in class status. So there's lots for all of us to be proud of on this slide. I am no way I'm saying that the UVM Health Network is the direct cause of this. We certainly are a participant, but so are those that work in state government and that regulate healthcare. Next slide. A little bit closer to home. Our home counties in Vermont of Chittenden, Washington, and Addison, lowest cost counties within Vermont. It's not a mistake or just happenstance that our three organizations in Vermont have come together. We have a very similar approach to delivering healthcare that's highly efficient. We're the lowest cost counties within Vermont and Addison County is also among the lowest five counties in the entire country. And again, the legend shows in this relative to the Vermont average, what the per capita, again per capita cost is in each of those counties. And I will point out when I've shared this before, folks say, well, that's because there's bunch of young college students diluting the needs in at least Addison County and probably Chittenden County. These are age adjusted. So this is about as close to apples. That's why the Dartmouth Atlas is the source of truth. So these are age adjusted. Next slide. You might say, I've heard this too, if you're such low cost, you're probably not producing on the quality side. This is complex slide, so I apologize for that. But this is the Commonwealth Fund that puts out a state by state report card, scorecard. I think on an annual basis, they might skip a year or two here or there. This is the 2020 report card using 2018 data. And this shows that overall, Vermont ranked sixth out of 50 states and the District of Columbia on their composite ranking. To dive a little deeper, affordability and access, just characterize this as a huge complex issue that we're all dealing with. Access here, if you look at the measures that underlie this rollup, they're really talking about access to health insurance and ability to afford healthcare in that access and affordability. And since we have had health policy that makes the vast majority of Vermonters have some form of coverage, that's how we end up fourth. So this doesn't take into account what I've acknowledged is a huge access issue. And then the next five that have to do with quality are composites of 60 measures that are bunched here and you can see our ranking. And again, this takes a village. I'm not saying that the UVM Health Network is the cause of this, but again, we're certainly a participant. And if we weren't hitting on all cylinders, Vermont wouldn't rank this highly. And I would say that my recollection is that we've been in the very top tier of this ranking every single time I've seen it. And a couple of years ago, we shared this report widely with every Vermont legislator and many in state government. Next slide. Network focus on diversity, equity and inclusion. And this is the last thing that I'm gonna speak to in the presentation phase. I'd like to thank the healthcare advocate for asking questions specific to our diversity, equity and inclusion efforts. And I'd refer you all, the board members to the answers that we've provided to these questions because it gives you a little bit, a lot more granularity on the resources that we're providing. I would say that like many organizations and in my view, particularly organizations in Northern New England were late to the DEI game in many ways, embarrassingly so. And since the murder of George Floyd, we are experiencing an organizational awakening. And this is across all of our subsidiary organizations across the UBM health network. And we've chosen to not just talk about the deep issues of diversity, equity and inclusion but actually to begin taking substantive actions to make progress along this journey. It actually starts, I'm going off my script here. Our network board over a year ago looking around the room and saying, we've got gender diversity, but we need a sense of diversity actually expanded our board and brought on four members that have added great diversity of experience, of thought, of lifelong lived experiences. So it started right at the top with our board taking substantive actions. Some of the examples of things that we've done at the management level, we've established an anonymous hotline for our employees to be able to call into if they believe that they've been subject to discrimination or exclusion in any way. We've completed a DEI workforce assessment done by a national vendor and we've shared the results of that back to each organization from the board down to the line staff. We've asked each of our organizations to create action plans based on those data and those action plans, many of which are being acted on today. We've designated the DEI leader at each of our subsidiary organizations and they have led the effort to set up multiple employee resource groups. Every single one of our organizations has at least one of those and most of our organizations have several and those continue to evolve. All of this has been based on not just top down, hey, that sounds like a good thing to do. We've had listening sessions, the academic medical center and Dr. Lefler have been real leaders in this open listening sessions where our employees have a safe place to go to talk about these issues and they've been a great source of learning for what we can do on the management side to actually have an impact and not just pay lip service. We have a three phase network plan that's informed by those listening tours and by a DEI advisory committee that I meet with personally every two weeks to float ideas, they bring ideas and before we implement anything, I test it through that group to make sure that what we're doing will be impactful and will resonate. We've had leadership training in implicit bias and also in anti-racism and how to be an anti-racist organization and I will tell you that the personal journey through those learnings is tumultuous and that self-reflection is really tough and we don't have that knocked in any sense of the word but we're continuing to work on that and we're also recruiting a Chief Diversity and Inclusion Officer, we're in the final phase of that with four finalists identified and I will tell you that it has been amazing the national interest that we've generated by that search and I believe we will have a leader that will come in and help us not only in the UBM Health Network but in our broader community as well. So in the face of all of these obstacles and all of the difficulties in healthcare delivery, why would we focus on this and put so much energy and resource into it is because it's the right thing to do at the end of the day for a caring and compassionate organization to focus on creating a place of belonging for everybody but if you look a little bit deeper, you know, we tout ourselves as a population health focused delivery system. We need to recognize the disparity in health outcomes that come with disadvantage and we need to measure along the path and we're just scratching the surface of how we measure and track our progress and also there's a great business case for focusing on diversity, equity and inclusion. Study after study shows that organizations that have a diversity of inputs, particularly at the leadership, make better decisions, do better in recruiting and retaining high quality workers and do better in meeting their missions and financially. So again, I thank the interest of the healthcare advocate for this. You'll be hearing a lot about this from our network and it's very much at the top of our priority list at this point. So I'm gonna be available for questions. As I said before, we officially got started and I'll help to farm the questions around but now we're gonna go into the bulk of the presentation. I'm gonna turn it over to our chief operating officer, Al Gobey to get us started on that. So to you, Al. Thanks, John. Good morning and happy Wednesday to everybody. Chair Mullen, can you hear me loud and clear? I can, thank you. Next slide please. We wanted to start the operational and financial briefing today with a conversation about some of the challenges that we're facing. We've written in the last two narratives about the good work that folks at the UVM Health Network have done, basically combating the pandemic. The update I wanna give you this morning though is where we're at as of today because in our narrative, we talked about the aftershock of COVID and we probably shouldn't have called it aftershock because we're still in the middle of it and I wanna be very clear on what I mean by that. We are seeing incredible patient volumes right now in our EDs, in our med-surg units and in our ICU's but they are patients that delayed care or have higher acuity than normal. It is not due to the Delta variant. We certainly have COVID positive patients in-house in our facilities but the volumes that we're seeing are really about the healthcare that was delayed when you saw our revenues go down. So that is presenting itself as the mental health challenge that John discussed and it is presenting itself as the med-surg and ICU challenges and ED challenges we're facing every day. Just a couple of examples and the presidents will elaborate on this. Our med-surg units at CVMC have a census today that is higher than almost anyone could ever remember it being and that is literally due to delayed care and our ED at UVMMC had one of the 10 hardest days yesterday that anyone could remember in terms of the number of patients and the acuity of those patients and so again, not COVID positive patients in totality, certainly a few, but the main issue here is delayed care. And again, the presidents can answer questions on this or comment on it, but I wanted the members and staff of the Green Mountain Care Board to know and understand just what we're dealing with right now, today, this morning. I'll also touch on a few of the things on this slide. We've talked in our budget hearing last year and throughout the year about the impact that revenue has had. Later in the presentation, I'll show some slides that go through the volume impacts of the second COVID surge and where we think we're at as of today and how that works into our budget. I want to be clear that COVID is an accelerator. So anything that was happening and sometimes bad, it may have happened faster. And so we've had to work really hard at controlling our expenses and managing our expenses. Anyone who's tried to buy anything understands that the supply chain is completely disrupted globally, not specifically to healthcare, but inclusive of healthcare. And so in the early days of the pandemic, the question was, do you have enough masks? We worked with the state, we worked with Dartmouth, we've secured enough PPE and we feel confident in our supply, but there are supply chain disruptions that cause us to work hard every day to make sure we have the equipment that we need and the supplies that we need. And we can talk about that in detail or have a future conversation if you'd like to hear more about that. Testing, for example, we've seen testing scale back. Now we're gonna be scaling up testing as our vaccine mandate takes effect with our employees while other employees do the same and as the Delta variant causes increased demand. And so what we thought was slowing is now growing in response to the needs of Vermonters. The last under COVID-19 that I'll talk about at this point in the presentation is vaccinations. Vermont is probably the best place in the world right now in terms of the population percentage that is vaccinated. We are incredibly proud of our teammates that work to help make this a reality by both giving out vaccinations but also a willingness to be vaccinated and we'll continue to lead on that. John's been very clear that we will mandate vaccines for our employees in both states, on both sides of the lake or that we will have regular testing. So I can't talk about challenges of the past 12 months without talking about the cyber attack and I'll get into that a little further in the presentation. If you take one thing away from this presentation today, it's the next bullet other than of course approving our budget. And that is staffing shortages. This is an incredibly serious nationwide problem that we are in the middle of. We are spending an incredible amount of money on travelers and locomtenants in order to staff our facilities. We are also partnering with organizations such as Birchwood to pay for travelers to staff skilled nursing facilities in order to get patient flow out of our med surge units because we have long-term stay patients that we need to find a bed for outside of the hospital and the flow of patients in the system, not just mental health but also skilled nursing facilities has been impacted by the pandemic and remain so. But staffing shortages is the key problem in my opinion that we face on all levels, central sterile, cafeteria, doctors, nurses, med techs across the board. Last, Fannie Allen and I see Steve in the frame here. This has been a really hard thing for the UVM Health Network and the University of Montt Medical Center in terms of the way we want to provide access to our patients. Both rehab and our surgical center have been impacted by the closure and we're working hard to try to address that both through planning our outpatient surgical center and with things that we can do in-house to make the situation better. But that has been a significant challenge. Next slide. This slide takes my breath away and put together with the next slide that shows the federal and state money that we received. I can't say it any simpler than we are grateful. We're grateful to the state, we're grateful to the federal government because if it wasn't for the money that we received close to $197 million, the $300 million in revenue that we did not earn in the two years, in the two fiscal years would obviously have driven these margins much lower. The 3.4% that you see for UVMMC on the green line is completely due to this federal and state intervention and would be headed towards $30 million in loss if we did not receive those funds. And so it's a good story of support. Without margin for capital, we simply cannot remain modern and that is important for everyone to realize it has sweeping implications across each of our facilities if we were to have lost the amount of money we would have lost, but also the $197 million from the federal government did not close the $300 million gap entirely. We did a lot of work on expense control and also capital spending to keep our days cash where it is and to also help offset some of the margin losses. Next slide. This is the chart that I just mentioned. I'm not gonna go into it in detail. We offer it as an exhibit of what we did receive over FY20 and FY21. Next slide. I've touched on many of the points on this slide and we've certainly talked about them in our narrative this year and last year. When I think about this slide, I think about our people. I think about our leaders and I think about what they've done for other human beings. I can't say again any better how proud I am of our teammates. Next slide. So on October 28th, we were attacked and we were the victims of a crime and just looking at this brings back the memories of that day and the subsequent weeks. We're grateful again to the state of Vermont for partnering with us with the National Guard. Grateful to the FBI and grateful to our IT folks who worked tirelessly to get us back in business. We could talk for literally hours about the response that we put into this when we had to basically rebuild our infrastructure and get to every endpoint, which is every laptop, if you think about it that way, in the network, 5,000 of them and basically re-image them. We have taken decisive actions since. When you think about the virtual private network that we were hacked through, that is a direct consequence. Believe it or not of the pandemic. As people no longer went to the office, they didn't go through our normal access channels and used alternative access channels that were not as secure. And so the decisive steps we've taken are to protect our network from any offsite access by employees. And so we feel the steps we've taken have been prudent and are protecting us today. But this is an arms race. We worry about PPE, we worry about vaccines, we worry about med-surge patients. These folks wake up every single day trying to think about how to hack us. And so we have people that think about that as well and we are trying to stay one step ahead. But we are not alone in this as has been seen over the last year. And this is a worldwide problem. Next slide. This is the structure that we use to secure our network. And so we have built a shared service meaning each affiliate doesn't do this on their own. We work together under one leader, Doug Gentile, to have the three pillars of engineering operations and risk and awareness all work together, but also to have the tough conversations about where we need to invest large dollars and where we need to frankly change our business practices to remain secure. Next slide. So from here, I'm now gonna turn it over to Rick and he's gonna talk about how benchmarks are guiding our return to solid financial footing. Rick. Thank you, Al and good morning, everyone. So as you heard in Dr. Brunstead's opening, Athena, I think you'll hear throughout this presentation is how we're trying to use benchmarks to highlight both where we need to be financially and how well we're doing at taking care of patients from a per capita basis and how efficient that we're being with our internal resources. Again, all looking and all being guided by external benchmarks. In this next section, I'm gonna highlight how we use benchmarks to guide our path back to solid financial footing. So the key financial metrics that we look at and we've had a discussion with the Remount Care Board staff that I think the staff are also starting to look at these metrics, which is great to see because these really are the key levers that guide us in terms of making sure that we're getting back to solid financial footing. The key with these metrics is they really need to be looked at together in concert. You can't focus on just one of these metrics because if you do both for us internally or for you as regulators, there could be something that you're missing in the story there. So just to give you an example, if for example our long-term debt was quite high and our day's cash on hand was quite high, that should tell you that we're too leveraged. We have too much debt and we've essentially financed our cash through borrowing versus having a good balance between borrowing and also generating cash through our operating EBITDA margin. So that's really the key here. I think the board and the staff know what these represent, the operating margin is what we generate from our core operations. We need to generate an operating margin from our core operations. We can't rely on non-operating revenue to support our needs. The operating EBITDA margin is a key metric. So this is our operating margin but highlights how much cash that we're generating from core operations. So it takes out the non-cash items related to depreciation, interest, and amortization. The last one on here, average Asia plant is a key, also a key metric. It highlights, are we keeping pace with the investments that we need to make both in terms of facilities and equipment so that these capital assets do not become obsolete. Next slide, Jen. So today we're here obviously focusing on our 22 budget for the health network but it's just important to point out that internally we take a longer term view of our finances. We have what we call our financial framework where we look out for five years. We update that framework every January based on the prior year's activities and what we know will be happening in the years ahead. Some of the ways that we, this really guides our finances and guides our path back to a solid footing. One of the very tangible ways that our framework is used is it actually sets the operating and operating EBITDA margin targets for us for the year so that the operating margins that you're seeing in our budget this year actually come directly from the framework. It's the number that we need to hit on that path. It projects our days cash on hand so we know where we are at compared to the target that we need to be at and how much money we'll have in that particular year to spend on capital. It also tells us as we look out, if we have debt capacity that we can borrow money to help support capital spending. But when you put all of this together, what the framework does for us is it ensures that we're on a path to continue to provide the access to care that those in our region in Vermont need. It's our scorecard, if you will, to ensure that we're on that path to meeting that need. Next slide. So this again, back to the works that we use. So we do have three mark sources that we use for these key metrics. They're also the same A side of the chart here. You can see that the benchmarks for these metrics are slightly different across the three agencies. So we look at that range in terms of setting our internal targets. So the operating EBITDA margin, for example, S&P is at the lowest at 7.3 with Moody's being at the higher end at 9%. So we use those to guide our internal targets. Our internal targets, as you can see on the right hand of the chart actually has a higher expectation for the UVM Medical Center. That's because academic medical centers that are part of a system have higher financial metrics than their non-academic affiliate system. Those benchmark ranges that you see there for Fitch, Moody's and S&P is the combination of the entire system. So it includes the academic medical centers that are part of those systems. The way to clearly see this is down on the bottom of the chart there. We've included a double AMC benchmark for, which is the double AMC CAUTH benchmark is all academic medical centers across the country. They don't have the same level of financial metrics that the rating agencies do. They focus primarily on expense related metrics which you'll see a couple of examples of that when Dr. Leffler gets to his presentation. But they do have a metric on operating margin. And you can see that the median for academic medical centers is 5% compared to the one and a half to 2.8 that you see there for the rating agencies. So based on that, our internal targets do have higher targets for the academic medical center. But when you look at the weighted average of our internal targets you can see that they very clearly line up with the benchmark ranges. So operating even a margin, the target that we have in our framework is from seven and a half to 9%. And you can see the S&P to fit ranges from 7.3 to 9%. So they pretty much all line up after you've done that weighted average. Important to note that these ranges that we have in our framework, the lower end of those ranges puts us at risk for a downgrade. So that's not the place that we want to be. We need to be at the higher end of that range to ensure that we're financially stable. And then the last piece that I've highlighted here in yellow because there is a deviation from our internal framework compared to what you see in the benchmark range has to do with our operating margin. So currently we have a higher target for operating margin than what you see in the S&P and Moody's. And that is directly related to the fact that we haven't spent the amount that we should have been spending the last several years on capital. Which means when you look at our profit and loss statement, we have less depreciation on our profit and loss statement than what you would find in other organizations. So hopefully, assuming our budget gets approved and we start getting on a path that allows us to spend more capital, that internal target will go down over time as more and more depreciation expense starts to become a part of our P&L. Next slide. I just included a quick example just to kind of show how that will happen. So this is, if you assume just static revenues and expenses, so no change there, but you start spending more on capital which will drive up the depreciation expense that we have. You can see that that doesn't change the operating EBIT of margin, but it does over time start to drive down the operating margin. So that's what will happen to our internal targets as well. As we hope we're able to increase our capital spending on much needed investments, our internal target will start to go down for our operating margin. Next slide, John. So this is a look at where we have fared over the last few years when you look at the internal targets that we've had. The yellow highlighted numbers are numbers where we're below our framework target for that given year. Green is, sorry, yellow is we're within the framework target. Green is we're exceeding the framework target and then red we're actually below those targets that we just took a look at at the previous slide. So the story that this really tells when you look at from 16 up through our 22 budget is we were on a good solid path back in 16 and getting into 17 in terms of our operating EBIT of margin. You can see that our cash still wasn't within range but was starting to climb as a network. It went from 188 to two or one. But from then on, our operating EBIT of margin started to decline, which caused the cash to decline and the decline as we'll highlight as we move forward through the presentation. Really the key missing piece there is our revenue rate increase did not keep pace with our expense inflation during that period of time. So that's kind of the key messages to take away from this slide. What this does show is we are in a, if you take a look at our long-term debt to capitalization ratio, we are in a good place there in terms of how we compare to the benchmarks and where we are compared to our internal targets. Once we are on a path where our operating EBIT of margin is consistently back into the range we need it to be, that's an area that will have more confidence in being able to take advantage of that debt capacity that we have there. Finally, if you take a look at the budgeted, the FY 22 budgeted column, you can see that we're the target that we've set for the operating EBIT of margin for this year is still at the lower end of that range. But if we can start to make some progress like we did last year, where our rate increase did come very close to covering our expense inflation. If we can continue to make progress there, you can see we'll at least be at the lower end of the range and hopefully in the years ahead, we'll be able to focus our benchmark targets on that A rating. The rating itself is not what we're essentially striving for, it's more about what the rating says. So first of all, 90% of S&P rated hospitals do have an A rating or greater. So the targets that we have set are not targets that are unreasonable, they're very reasonable that they're where we should be as an organization. The A rating indicates the financial capacity that we have to care for our community. It indicates that we have the resources to pay competitive salaries, to recruit and retain the people that we need to care for our patients. It signifies that we can keep pace with advancements in medicine. It signifies that we have the financial stability to weather unexpected events. Back to the deep appreciation that Al shared when he was talking about the federal and state stimulus money that we received. The fact is at the beginning of the pandemic, we were in not the greatest financial shape to be able to weather an event like that and had that not been for the federal and state funds that we did receive, the impacts of the pandemic and the downturn and in our finances would have been even more dramatic and even more impactful to us continuing to meet our mission. So we wanna get back to that place where we have the financial stability to be able to absorb those unexpected events. Something very tangible that the A rating means is that it ensures that we have access to capital markets. So when we do need to borrow money, we have that ability and it also ensures that we have low interest rates on that, on those funds. The rating agencies and their meetings with us this past year made it very clear that they're expecting the health network to be back into that seven to 9% operating EBITDA margin range or that we were at risk for a downgrade. They've seen even before the pandemic that our finances were starting to deteriorate. So they're really expecting this next year that we're back into that range. Then finally, what that would mean if we were to receive a downgrade, it really would mean that we don't have the financial wherewithal to continue to make investments in our people, in our facilities, in our technology, that the organization would seriously be at risk for not being able to continue to meet the needs of our community. So I think that's it for, so I'm gonna turn it over to Mark who is gonna highlight our net patient revenue growth and then also go into detail on our commercial rate increase. Thank you, Rick. So as I go through these sections, Rick and I are gonna be sharing some of the talking points back and forth. So there are a couple of slides he'll be doing. There are a couple of slides up. I'll be doing, but I'll be pausing at the end to see if Rick has anything to add. Next slide, please, Jen. So this is just an idea of how we go about constructing our net patient service revenue budget. It is very consistent. It is very system-driven. There are nuances that need to be factored in for the three different hospital types, but this is basically the practice that we've been doing for many, many years that has gotten our NPR rate, I think, fairly close to target each year. Understanding the last two years to Al's talking point earlier, there's about $300 million worth of less NPR coming into the system over FY20 and 21 for our hospitals. So the first column, you know, this just highlights what goes into the 21 budget, all of those same general assumptions. And so what we attempted to do here is to say that these are the components of how we break it down and speak to the major items that drive it. And there's some notable items at each one of the bottom. That's more there from an awareness perspective, but I can't overemphasize how important that base period of the year to date, October to January is for this overall model. I mean, that is really, really the foundation that establishes all of those relationships of payer mix, service mix. So in the emphasis is probably more important than this year than ever before. As Al spoke to those challenges earlier on an earlier slide, all of those challenges hit in that October to January period. And so the challenges that we had as a network is that we take that October to January base period and then we say, what sort of adjustments do we need to make to that? To basically get the simple example that I use is that before you look at any rate changes, you know, how do we make September look like it's a 12 month budget? How do we align? All of those dollar values that happened in September as a 12 month budget and as you're going to see in a later slide, you know, from Al on volume that also presented a little bit of a challenge this year, I shouldn't say a little bit, a significant challenge on how to predict where 22 is gonna fall. For some of those challenges he mentioned earlier and some more that he will mention later, so here's how we went about it. October to January still served as the base but we had to go in there and do more adjustments than we have ever had to do and I've been doing this more than 20 years, more adjustments than we've ever had to do and basically what we had to do is we went back and we looked at 2019 actual, that was the cleanest year that we had and we basically looked at 2019 actual and then we looked at October to January and then also all of those adjustments that need to happen or be taken in consideration and we put our best work forward taking all of our expertise and this goes all the way down with a revenue chain by the way of saying how is this gonna impact us as we go into next year? So like I said, there was a lot of considerations, there was a lot of changes but we took a mix of 2019 actual, the October to January base and the known adjustments that we would have and then we said, is there any changes in utilization? It's very difficult to come to a single utilization statistic that say this is how revenue changes. So the proxy that our model uses is gross revenue. It's not perfect, but it's probably the best that we have. The imperfections with it is that it really doesn't give the credit to each type of volume of how the value of that payment may change. So there's some fluctuations there. Then there's the physician, acquisitions or transfer component that needs to be considered. And then we take a look at what is our 22 expense inflation? And that's purely on rate, that's purely on unit cost change. And we're gonna get into this calculation next and you total those all up, that's how we get to our 22 budget and you see like the same list of base assumptions that you saw starting with 21. Next slide, please. Okay, so these are the numbers that go along with it. And so, and I'm gonna speak first to a little bit of that scalability that John spoke to earlier that it's important to keep in mind that when you look at some of these numbers, they are big numbers, they are large numbers. But when you put it in relativness to the base in a very complicated payment model of how close that we are actually able to get these numbers, it is pretty remarkable. So, but I'll go through and I'll speak to each one of these at a high level for each one of the facilities. There was the most variation at the University of Vermont Medical Center. The starting budget was $1.4 billion. Through that base period and through those adjustments, there was almost $47 million of changes. I can tell you there was a pair of mixed change where that took that down by a significant number. And we did see a change in our budgeted collection rates by payer. That was attributed to a shift in the mix of services. And Al spoke to this earlier, meaning the acuity or the treatment levels that had to be provided to patients were at a higher level. And it is just the way our payment structure works, okay? Those higher acuity services, like a surgical case compared to a medical case, even if the gross revenue is the same on both of those cases, the surgical case is usually paid a little bit higher. So that acuity mix was a large, large driving factor of that $47 million change. There was a little normalization in there of transitioning like the hospital rate year to a calendar rate year, so on and so forth. That accounted for about $9 million of that $47 million. But the major part of that was a change in the type of services that the patients were seeking out. The utilization for the University of Vermont Medical Center was basically a push, I would say. And keep in mind, Al's gonna speak to the volume later. There was a physician transfer between two of our organizations. Well, the rate increase that was necessary to cover expense inflation was $42 million. And that's what brings us to the $1.5 billion. The rest of the two organizations, CBC and Porter, they were a lot more normal of the year. And I also should say this too, is that that $47 million, I look back that past year's filings, it is a little bit higher than past year's filings. So that's probably that volatility that we had to do in that adjustment period. But when you look at CBMC and Porter, the adjustments were much, much smaller through the base and the adjustment period. You can see through their utilization that we are predicting a utilization increase. Al's gonna speak to those volumes later. Their expense inflation was respectively $6.8 and $2.6 million that brings CBMC's NPR and FPP budget to $251 million and for Porter $94 million. And then if you break that change down in totality, that for the University of Vermont Medical Center, that's a budget to budget NPR change of about $85 million. If you look at after the physician transfer column, you know, respectfully, the staff still need to do their work with the Green Mountain Care Board to calculate those percentages. But if you look at it after the physician transfers, that's about a $6.3 million change and 3% of that $6.3 million is related to the 22 rate change that is directly tied to expense inflation. And Rick's gonna talk a little bit later on the difference between those two slides and how you break all of this down when you look at it on a population basis. But if you look at it at CBMC on the surface, it looks like they had a very large NPR increase of 6.5%. But after you factor in physician transfers, it goes down to 4.5% and their 22 rate that's related to expense inflation for 22 is 2.9%. And then if you look at Porter Hospital, it is 4.9% and 2.9% respectively. Next slide, please. Yeah, so this slide is meant to just highlight a couple of things, but primarily because you'll see in a minute as we did last year, our commercial rate increase is completely being driven by the need to cover the inflation on our expenses. And so when you think about volume or expense increases, there are expense increases that are generated by volume and then there are expense increases that are generated by inflation. And when we look back at our finances over the last several years, if there was no expense inflation in our numbers, and we just had a volume increase that then had a corresponding expense increase. With all the fluctuations in terms of the types of volume changes that we've had over the years, whether it was admissions or radiology exams, different payer mixes, different amount of fixed versus variable expense on that particular volume metric that was increasing, you take that all into consideration, essentially our margin would have just been essentially unaffected by volume changes over the years that the revenues and expenses essentially were pretty much in line. Meaning if we had no expense inflation, we would need no rate increase because all of the moving dynamics within our finances of changing volumes and the things that we've done to help manage expenses all essentially brought us to a kind of a level kind of margin. What has been missing is that rate increase to cover and keep pace with the expense inflation. So that column B that you see there and that small grid down the bottom, that's been what our struggle has been, that because we haven't been keeping pace with that expense inflation, we've been losing ground in terms of our margin. Last year we made great progress where the revenue rate increase came close to covering our expense inflation. So hopefully we can continue to make that progress, but that's really the missing piece. And as you'll see here in a minute is the piece that as we've done the last couple of years that is how we build our commercial rate need. Back to you, Mark. Next slide, Jen, please. Okay, so this is how we went about our commercial calculation. It first starts with what the expense inflation was for all of our payer population. And when we say expense inflation to be very, very clear, we are only referring to FY22 expense inflation. So we're looking ahead, we're trying to pick, we are trying to predict what that looks like. And that's what we're building into our ask. We're not doing the look backwards. I mean, as we all know that the expense inflation Al spoke to earlier in 21 was probably higher than most, if not all hospitals budgeted. So this is only 22. And you're gonna hear at the end of our slide presentation what some of the risks are. One of the risks is this expense inflation that we're building into our 22 budget isn't high enough based upon what we're currently seeing in the marketplace. But this is what it was based upon. So we first start with the expense inflation number. We take away all of the other payment increases from the non-commercial payers. That equals with the remaining expense which needs to be put onto the commercial payers. We divide it by the per 1% and that does the solve for the commercial rate. So that's basically how we do it. And we'll go through the numbers for each one of the affiliates. Okay, okay. So the first thing I will say this is where the expense side really matches up with the NPR side, okay? And the numbers might not match exactly because we're trying to go after it from a payment level and an expense level. So there's a little variation in the rounding here. But basically, if you take a look at the expense inflation for the University of Vermont Medical Center, the total expense inflation was $41 million or 2.5% from an expense level. We did have to back out a portion of that was related to our other revenue activities. So basically the net starting point of how much fell into the expense inflation that needed to be funded by NPR was the $38.6 million. I'm just gonna go through these categories and just kind of share what the change was. So on the salary inflation in this one, it was 3% or 3%. On the med surge, it was 3.2. The pharmacy, it was 2.8. The other category was 0.9%. And the expense inflation on the provider tax is purely related to the unit cost change in the revenue. That's one of those categories that it's just not one calculation. It's a three or four step process that you need to consider as you go through that. And we're happy to talk to that further at the end of the presentation or with the Green Mountain Care Board staff after. But it's very important that you consider those three or four steps. And another way of looking at it is how is the expense changing if the volume doesn't change? So that's another way of looking at it too. But basically, if you go down below the first column, well, that says if we were to out and by the way in the little assumptions after Medicare, that just shows the Medicare inpatient assumption was 2.5% outpatient to professional was 0%. It looks like it was cut off. The basic assumption in Medicaid was zero. It says a minus here, but that's where we're getting to some of that rounding aspect. In the model, you need to consider other payers and bad debt and free care and then commercial. But if that 38.6 million and I'll know this is part of the rounding, it's off by 15,000. But that's just the multiplier on large numbers is if the expense inflation was to be funded equally based upon the current mix of business, this is what it would look like for each one of the payers. Medicare would be at 11 million. Medicaid would be at 4.5. This other category would be a little bit over a million and the commercials would be about 22 million. Based upon those assumptions that were shared off to the left, these were the rate calculations in the model. Medicare funded 4.2. That was basically zero bad debt and free care, which was the main driver and the other payers went backwards. And that meant to balance out the solve for to the end that the commercials ended up with $39.5 million. You can see the difference off to the right. And if you take that $39.5 million down below, the per 1% on a budget year is $5.6 million in that calculated 7.05% rate increase. So next slide, please. So going through the same mechanics for the central Vermont Medical Center. Their total expense inflation is 2.3%. Once again, it is fairly modest if you look across the individual categories. A salary infringes 2.5%. Med Surgeon Pharmacy are 3% and 4%. All others under one in the provider tax is about 2.4% compared to the unit cost change down below. This just speaks to the same thing. Their assumptions were 2.5% for inpatient Medicare, 2% out and zero. Medicaid was zero. Here's the impact of bad debt and free care. If you allocate that $6.1 million across all of the payers, it is 2.2 million for Medicare, a little under 800,000 for Medicaid. The miscellaneous category is 250 and commercial payers are 2.8. Once you factor in the cost shift, it brings us down that the commercial payers have $5.8 million. You go down below, you take that $5.8 million, divide it by the per 1% of the 791,000, and that's how CVMC comes to their 7.41% commercial rate. Next slide please. Okay, so as we look at Porter Hospital, they had a pretty low cost inflation total. That's about 2.4%. Their salary in fringe was 3%, well, the mid-surge was in the 3%. And then the other thing that I should say is all of these numbers tied to the appendix table that we submitted under the inflation category. So if you wanna reconcile those numbers, that's exactly where they come from. So on forth going, all other was under 1%, whether the provider tax was 1.8% that was in line with their unit cost inflation. As you go down to the rate assumptions, Medicare inpatient, outpatient had a 2.4%. That's a little bit different because they're cost-based reimbursement. So on the hospital activities, so it makes sense that 2.4% is exactly in line or very close to being in line. With what their cost inflation is. On the professional, since they're not paid that. Way on a cost basis, it was 0%. Medicare was zero. So just to kind of outline this, I mean, where you can see going across, there's 800,000 for Medicare, 200,000 for Medicaid and 1.1 million for commercial. You can see that Medicare for cost-based reimbursement comes a lot closer to funding that inflation cost. It's a much smaller number. So the solve for there was a little under 1.9 million dollars for commercial is 321,000 per in. And so that calculates a commercial rate of 5.86. I would just like to say that, this is just one aspect of the NPR change. Rick's going to be talking about the next aspect of the NPR change. And how you start to transition this look of an NPR change and start to look at the impact of it, of when it's evaluated across the population base in our service area and exactly what that means. So I'll hand it back to Rick now. Thank you. Next slide, Jim. So yeah, as Mark was saying, so what we just went through on those slides is the rate component of our NPR. The other component is the utilization piece. So what I'm going to take you through the next few slides is how that rate and utilization compares to the population we serve and make the case that when you look at it from that lens compared to the denominator, which is the population we serve that we feel we're within the 3.5% net patient revenue growth guidance. Jen, next slide. So in asking that our net patient revenue growth be viewed in that light on a per capita basis, obviously I hope we're agreement that we're not asking the board to go beyond the bounds of the statutes that regulate us. So hopefully that what we're about to go through makes sense to you. Next slide, Jen. So when you think about total cost of care as I mentioned, so it's a combination of the price for the services times the utilization that we're expecting. So our total NPR is essentially that total cost of care. It's what we're projecting for the price of the services that we have, including the commercial rate increase that we're requesting in this budget, times the utilization that we're projecting for all the different volume metrics, admissions, radiology exams, the everything that we have in terms of utilization. The next piece of that equation is then taking that net patient revenue number and dividing it into the population that we serve. Since as one of our key and core missions is trying to keep our population healthy, we're actually trying to decrease utilization. So you need to look at that denominator because that indicates the patients and the population that we serve that haven't received services, which is obviously part of our goal. Next slide, Jen. So some of the bullets that I have in here and some of the talking points have changed even in the last two weeks here, but we submitted our presentation a little while ago. So I'll just highlight some of the things that have changed. So overall, as we've highlighted the last few years and as I'm sure you've seen, the population in Vermont has been flat through 2000 or was flat through 2019, but that our primary network, the counties that surround Chittenden County, so Addison, Grand Isle, Franklin and Washington counties have been growing even though through 19, the population of Vermont has been flat. We saw in mid-April, the newest census data that came out that showed that the population in Vermont had grown from that 2019 estimate of 623, almost 624,000 people up to 643,000 people. So a very unexpected result and that's even before we've seen any kind of data on what's happened in 2021, which I expect when we do start to see some data, we're gonna find that that number has grown even beyond that number. At the time that we submitted this, we did not have the census data available by county that did come out a couple of weeks ago and it has essentially validated our sense that our market area is growing. Al later on in the presentation is gonna share some of the results of an independent study that we had commissioned that will show you a little bit more detail on where we think that that's headed in the years ahead. Like the rest of the Vermont, the UVM Health Network's primary market area has been aging. In 2018, we were fourth in the country as a state where we had 19.8% of our residents that were over 65. And this newest 2020 census data that's grown to 20%. The reason why that's important as we all know, the older that you are, the more you utilize healthcare services in this chart at the bottom of this slide highlights the data that has been put out there by the Department of Health and Human Services that shows that those 45 to 64 use healthcare services at two and a half times those under 45 and those over 65 utilize healthcare services at almost four and a half times those under 45. Next slide, Jen. So this model that we have built to adjust our net patient revenue on a per capita and age adjusted basis, we had in our narrative, we've condensed it here in the presentation just to highlight the kind of the key pieces of information. But if you're looking for more detail, the chart is a little bit more expansive in the narrative. Starting at the top is our market share over the years. So for FY21, for example, it's that 325,000 figure and this is the market share for all three of our Vermont hospitals. Again, just as we're going through these numbers, just to remind everyone these numbers that you see for 2021 and the 22 budgets are before we had access to the most recent census data, which shows that these numbers actually should be higher than this. So when we update our model, it will change these numbers because the population is actually higher than what we have in here. One of the factors that we've used as again as we highlighted in our narrative is to adjust the population for the age of the population and to use those utilization factors from the previous slide to make those adjustments so that we factor in as population, to the age of the population changes that we can measure the true impact of that when you look at net patient revenue so that we're comparing apples to apples. We've taken our UVM health network patient revenue and we've taken out all the New York based net patient revenue so that we're truly only talking about the net patient revenue that's been generated by Vermont patients so that we can compare that to the population numbers. This next section here on the slide we've added, we didn't have in the narrative because on the next slide, I'm gonna compare this number to some national trends. Again, trying to use benchmarks wherever we can so that we have some external look on these numbers. But when you look at the last five years at our net patient revenue per capita, not adjusted by the age, we've averaged 1.2% increase in net patient revenue over those per capita over those five years. When you look at our budget to budget change, we're at 3.9% per capita. Again, these population numbers are lower than what we know today. So both of those percentages with updated population numbers would generate lower numbers than what you have here. And then finally, the grid at the bottom that is the age adjusted number over the five years, the net patient revenue per capita adjusted for the age has increased by 0.2% over that period of time. And then finally, from the 21 budget to the 22 budget has increased by 2.6%. And it's that number that we feel strongly fits within the 3.5% guidance that has been set by the board. Next slide, Jen. So here just to show again, how this compares to some external, not necessarily benchmarks, but data. As I just went through the UVM Health Network from the non-age adjusted per capita growth from 2016 to 2021 has been 1.2% over that period of time. The national growth rate, if you look at the chart at the bottom over that same period of time has averaged 4.4%. The non-age adjusted per capita MPR growth rate from our 21 budget to our 22 budget is 3.9. When you look at that 22 increase again on the chart below for the national projection, it's 4.9. Again, both of those numbers will be lower when we update with the newest population data. And then finally, not something for necessarily this budget hearing or to use for today, but just looking ahead a little bit when you look at the data, the national growth projections, and you look from 2022 to 2028, the national per capita growth projections are 5.5% per year during that period of time. So just putting it out there that we know that the Vermont population is growing faster than the rest of the nation. And we know that utilization of older folks generate more utilization that looking ahead that 3.5% growth target number, even when it's adjusted on a per capita basis based on these projections that are being made may be difficult to achieve and just something we need to consider in the future. With that, I think I'm now turning it over to Dr. Leffler to share a little bit about the EVM Medical Center. Thank you, Rick. Steve, before you start, at some point in the next 45 minutes, we would like to take a 10 minute bio break. Is now the logical time for that or should we wait till after your portion? Sounds good to me. Let's take a break. Yeah, I think this is a right breaking point, Kevin. Thank you for bringing that up. Thanks, John. So I'm going to recess this meeting until 1020 and we'll see everyone back at that time. Thank you, Kevin. Next slide, please, Jen. So I think it's an important point that the EVM Medical Center serves both our local community and the entire state. We're the Academic Tertiary Care Center for approximately a million people in Vermont and upstate New York. We're also a very large community hospital and our employees serve almost 170,000 people in our local region. That's critically important for everything we're going to talk about today that we have this dual function. I can tell you as a provider and educator, that's an amazingly great place to be to have both a community hospital and academic medicals on COVID-19 and we committed using all the resources that we had to support Vermont's pandemic response, whether that was testing Vermonters, vaccinating Vermonters, standing up surge sites, one of our infectious disease providers, concessions to underrepresented Vermonters to help them make good choice to be vaccinated. So across the organization, people were very committed on using the resources of the Medical Center to help Vermont, I think have the best in country response to the pandemic. This slide was put together when we were optimistically saying we're going to return to many pre-pandemic capital projects, but the pandemic, even though we wanted to be done with it, it's not done with us. We have 13 people in the hospital day with COVID-19. We have five in our ICU who are quite ill. That's down from 15 over late last week. And we have 54 people waiting for discharge who can't leave the hospital, but are ready to because we don't have safe places to send them. That's mainly pandemic related and staffing. We do need to get back to the other important work that we do and we are very focused on projects around staffing, equipment needed, like MRI machines and space. I've outlined some of the things that you're very aware of because we've put a ceiling in or I've told you we're going to, we're working hard on a staffing collaborative with our union to make sure we have safe staffing on all of our floors that's worked very well. Our emergency department, I've been here for 28 years. We've set our top number 10 days over the past three or four months. Yesterday was a day of 210 patients. I'd only seen that a couple of times before in my entire career and we're breaking 200 almost every day now. We need another 3T MRI. We have backlogs for MRI right now. We have the only 3T MRI in the state of Vermont currently. It runs 17 hours a day. We do our inpatients during the nighttime so we can make sure we get out patients in. 3T MRI is the state of the art for diagnosing cancer, another complicated complex illnesses and we desperately need another one for access for remoners who need that study. And you've already heard a lot about the FANY, a huge challenge for the medical center, but we need a current modern flexible outpatient surgery center for the patients that we serve, for our providers and for our learners that can understand as more surgeries move to outpatient care, how that would work for them and the future careers they're gonna have. Next slide, please, Jen. Our challenges, and once again, you've already heard this in the presentation, but I have to hit on this. We have a significant access challenge right now. As great as any challenge I've seen as long as I've been here, I think that the growth of Chittenden County as well as the aging of the Vermont population and the coming out of the pandemic with people being, having delayed care has put us at a critical time right now. Last Thursday, we were in near crisis mode in terms of trying to care for everybody who needs our services. The whole United States right now is having staffing challenges no matter what you're doing, healthcare, particularly is having huge challenges. We are having staffing challenges right now and working hard to make sure that we are an employer of choice, that we are recruiting well, that we're retaining well, that we are pipeline to the colleges that are training our next generation of providers. But staffing I think is gonna be a challenge for the next five to 10 years and we have to make sure that we are a place that people choose to work. Space, right now at the medical center, we are using every available space we have. In the early spring of 19, I came to Greenmont Care Board and we asked for permission to use some space and since that time, we're using all that space every day right now. We recently asked to add 15 more beds and even that right now is not meeting the demand for patients that we have. In our emergency department this morning, we have 22 psychiatric borders. We have 43 total patients and we have three people, this is actually a very low number, three people in our ED waiting to go upstairs, but we have five people outside hospitals that need to be transferred to the academic medical center that can't come. That's ideally a occurrence as a physician that really bothers me. I wanna get people to where they need for care. So we're very focused on that in trying to have space and staff to care for people across our region who need us. Next slide, please, Jen. So I wanna make sure that people realize that the pandemic as Al said has been an accelerator, we are having issues before the pandemic. If you look at the medicine volume up through 19, this is pre-pandemic and the surgical volumes, they were both already increasing. Then we get a dip from COVID, people stopped seeking care, we stopped doing a lot of care, but since about April, we've been back at least on these two curves if not greater. So we were already experiencing challenges around having space and equipment needed to care for people who need us. And since about April, it's been at an unprecedented increase. Next slide, please. So we break every single day at the medical center into three levels of capacity. So green is level one, that means operations as normal. The way I think about that is we have enough staff and space and equipment for everybody who needs us. No problems. Blue means we're challenged, but we'll get through it. Blue as we call it level two. And blue is not an easy day, but we have, we'll get through. And the upper level here, the orange or yellow, is we're at census level three. It can't be operations as normal. It means you have to divert people away from normal activity to figure out how to care for everybody who needs us, both with staffing and space challenges every day. You can see that for the month of May, May and June, we were in either level two or three every single day. We've been in level three right now for seven consecutive days. We project to be in level three all the way through at least mid next week. That means that the staff here is working exceptionally hard trying to manage patients and trying to get everyone what they need in really difficult circumstances. Extremely challenging. On top of that, I just will tell you that we're gearing back up for another major testing and vaccine campaign, the medical center through the fairgrounds through a lot of great partnerships, vaccinated, you know, 83,000 vaccines through the fairgrounds. We believe almost all those people are gonna need boosters now and we believe that with the challenges you're seeing in front of you in terms of managing the high census at the medical center, we're also gonna be doing another huge testing and vaccine campaign that we believe is gonna last through at least February. We look eight months out from everybody's first vaccine. So through what looks to be a very busy fall, high volumes of COVID patients, sick patients otherwise, high volume of transfers, site crises, we're also gonna be running another major COVID campaign which is the right thing to do, but we'll be challenging. Next slide please. This I already hinted at this, but you can see that from March 21 through June 21, there's a gradual but steady increase in patients or I would say outside facilities requesting transfer of their sick patients to the medical center. I wanna be clear, this is our mission, this is what we're here for. We need to be in a situation where we can accept every one of these patients as soon as the outside hospital says they need to come. So that we maintained for the whole pandemic even during the cyber attack that we would accept critical patients, emergent transfers, and we've done that consistently even today. But with already multiple people in the ED waiting for admission, some of these people have to wait for a bed. There's just no place to put them. So that's a critical issue we have to address. Next slide please. I wanna make sure you know that even during these challenging times we're very focused on being efficient and making sure that we're not using resources in ways that don't make sense and that we're controlling the cost in every way possible. This is a slide from what's called AAMC, the Association of Academic Medical Centers. It's about 130 medical centers including this in this chart, including the UVM Medical Center. For as long as I've been here, we've always been an extremely low cost academic medical center. This is directly with our peers. You can see that on this chart, we never even hit the midpoint 50th percentile or oftentimes at the 25th percentile or lower. So we are doing everything in our power to manage expenses and actually not to over utilize resources. When I tell you that our MRI machine is running 17 hours a day, we're one of the lowest utilizers of MRI in the United States on data. Next slide please. Another slide just to highlight that. Supply expense for adjusted discharge. You can see that we consistently are extremely low cost compared to the College of Teaching Hospital median. And finally, if you look at our compensation ratio, so that's basically our cost of staff per budget. We maintain right at A rated median right there, if not slightly below. I think that's my last slide, Jen. Yes, thank you all. Thanks, Steve. Morning, everyone. I'm gonna give a brief overview of Central Vermont Medical Center. Next slide. So just to reground us, Central Vermont Medical Center employs 1700 staff members and we serve over 66,000 people in the regions across our 24 cities and towns. On our main campus, CBMC provides a range of inpatient and surgical services as well as our long-term care and short-term rehabilitation at Woodrich Rehab. I do wanna note that since the beginning of the pandemic, we launched our incident command center on March 9th, Woodrich Rehab and nursing has had zero positive COVID residents, which is almost unheard of in the industry. So I just wanna credit the team for all the work and making sure we kept our residents safe through that, this very challenging time. CBMC also has 25 medical specialties and 23 medical practices across our HSA. We as all organizations in our network have been acutely focused on our pandemic response, doing all we can to support our community. We gave 34,000 vaccines in our hub in the Berlin Mall and we as UVMMC are preparing for testing, for our employees again, as well as the community and vaccine boosters. We are seeing as Steve mentioned a dramatic increase in the complexity and the acuity of our inpatient admissions. Most of our inpatient admissions are medical and most are over the age of 60. We've also seen high volumes in our ED, again unprecedented for us, as well as extraordinarily high volumes in our express care, some of the highest volumes we've seen in my tenure of the last four years. And again, the number and severity of our borders in our ED have increased through the pandemic, both for the adult and pediatric mental health borders. We're also experiencing medical borders in our ED, significant volumes increasing there. And as Al mentioned earlier, our acute care census is the highest that we've seen in my tenure. Next slide. Just wanna go over some priority areas for CVMC. I'm gonna spend some time talking about workforce a little bit later in the presentation, but I do wanna mention that for us as with Porter, we're gonna be going live with Epic Wave 2 in our acute care setting as well as our revenue cycle. We're looking forward to being on the same platform across the entire enterprise. And we are anticipating that with the increased census and staffing challenges that training for that will be a bit challenging, but I think as a network, we've been proactive in trying to secure additional staffing to support a successful goal live. The other focus areas for CVMC are in margin improvements. We've used a variety of lean and rapid cycle improvement methodologies to enhance efficiency of all of our operating systems. I'm gonna focus on a couple of projects in particular and those being optimizing our surgical schedule. So in collaboration with the UVM Health Network team and UVMMC specifically, we've opened up an allocated OR space and resources to provide OR time to UVMMC surgeons to come here and provide care for patients who live in our catchment area. I think that's a strong example of the effectiveness of the network. The other area focus for us is in our OR supply chain management and optimizing of our supplies in that area, reducing inventory and cost of limited use items. Again, just to reduce our overall expenses in that area. In the diversity, equity and inclusion area here, again, Dr. Bromstad shared a lot of what's going on at the network here specifically for CVMC. We've charted diversity, equity and inclusion steering committee in August of 2020. They meet monthly. That team reflects the diversity of our employees here. Very engaged team. As Dr. Bromstad mentioned, we have a lot of work to do. We did get support from our board of trustees for DEI commitment statement, which we've launched and is now part of sort of the grounding foundation work for all of our DEI efforts. We have declared Martin Luther King as an observed holiday, switching from a traditional Christian holiday of Christmas Eve to keep it budget new control, but that was an ask from our employees. So we wanted to move forward in that direction. And DEI content now as part of the education is part of all employee orientation, including our physicians that are part of our medical group. Dr. Bromstad sent a letter to the board in mid July, describing a large number of facilities projects within our network. And obviously core to that is our inpatient psychiatric capacity project. That project is essential to address a severe shortage of inpatient psychiatric beds that we're experiencing across the state of Vermont. We've already talked about the border issue and these patients, as you know, wait in our EDs every day of the year. And that is only increased in severity since the pandemic. We've done a detailed analysis of the statewide need and we acknowledge that we think that we can address that need to some degree by adding 25 additional adult inpatient psychiatric beds here on the CVMC campus and relocating 15 beds that currently exist for a total of 40 beds. Dr. Bromstad has reconstituted the PIC Steering Committee, which he will chair. That committee is picking up where we left off when we paused our planning efforts in April of 2020 at the beginning of the pandemic. We're beginning to explore more affordable options for creating more inpatient psychiatric beds here on our campus. And once we've determined the most efficient location for the beds, we expect to be able to take full advantage of all the planning that's happened to date. And that occurred prior to our COVID related pause. And we're looking forward to providing Green Mountain Care Board an update in late fall of that project's progress. Related to the pandemic response, I think we've already talked about what we've done to address it. And we are now working as a network to talk about how we address the booster needs, as well as the mandate for vaccinations going forward. And so that work is underway and we expect to be able to provide those resources as part of a network response. Other key initiatives that I wanted to mention, and the first one is the Central Vermont Prevention Coalition, drug, alcohol and tobacco use are leading causes of death and disability in the Central Vermont area. And that was as a result of both data we receive nationally, statewide, and as part of our community health needs assessment. We've launched a Central Vermont Prevention Coalition, which is an interdisciplinary collaboration of organizations and agencies that are working specifically on primary prevention, harm reduction and disease prevention, treatment, recovery and restorative justice. CVMC serves as the backbone organization for this effort in Central Vermont. We received a three year federal, rural communities opioid response program grant of $1 million. And over the next 18 months, this team will analyze the impacts of the COVID pandemic on substance use disorder recovery and ways in which we can really strengthen our treatment pathways. Another focus area as Steve mentioned is access for us. We've rapidly expanded and we continue to invest in telehealth services as part of a joint partnership with a health network and their patient access and service center. We're a pilot for some of that effort here and we're working hard to try to expedite referrals throughout the network for some specialties like urology and more locally rheumatology and endocrinology. So access is still a focus, though again to Steve's point, access is challenging with individuals having I think delayed some preventative health measures during the pandemic. The other area of focus for us is our accountable community for health that's called Thrive here. CVMC serves as the backbone organization for all that work and we're focused on improving the social determinants of health. This team's goal is to optimize the health and wellbeing of our community through informed, collaborative and innovative solutions. CVMC has worked collaboratively with 54 partners and they were essential in our, I think a robust community health needs assessment that we completed in 2019. And we're continuing to use those data to drive our focus areas as part of our strategic plan. The other area I wanna mention is the working community challenge. This initiative was launched in 2019 and it supports diverse local teams tackling complex challenges facing their communities. It's a three year grant that is cosponsored by the Federal Reserve Bank of Boston, the state of Vermont and national and local philanthropy and private sector employees. Eight communities in the state of Vermont received a grant and Barrie was one of those communities. And we're really grateful to be able to leverage our accountable community for health to do this work. So our focus area here in the Barrie community is by 2030 there will be 15% fewer single moms living below the federal poverty level than their counterparts in 2020. CVMC is a core partner in this program working with Green Mountain United Way. And we're specifically focused on expanding a program that we've been using here at CVMC called Working Bridges with Green Mountain United Way. And we're looking at how we can bring resources to those single moms that have dependent children and how we can really optimize the supports they have to allow them to really fully engage in the workforce. So that's work that's underway. And again, I wanna highlight our work on food security and wellness. This is work we've been doing for a number of years. That collaboration was more critical during the pandemic. As we know, food security was a huge challenge for many of our community members during this pandemic. So we've continued that effort serving over 300 households every month. And in addition to 150 households getting weekly healthcare shares with a very strong partnership we have with the Vermont Youth Conservation Corps workforce. Again, you're gonna hear this repeated, I think from all of us. And I know you're all aware that the Vermont Department of Labor noted that Vermont's workforce has shrunk to the slowest level in 30 years. So our workforce peak was in 2009 and now it's down to that same size as it was in 1994. So much of that decline has been in the last 18 months. And we're certainly feeling the ramifications of that in the healthcare systems. Reasons for that a challenge is an aging out of the workforce. Not only are our patients demographic shifting, but so are our employees. Availability of affordable housing is also a challenge. And then again, the pandemic impacts. So the staffing challenges that we face here are all over the board entry level positions but particularly acute in the RN sector, radiology texts are also an area that in the past we've not had challenges with but we are today. So one of the things we're doing is exploring EB3 visas to place foreign nurses into permanent positions here at CVMC. The goal is to bring talent into Vermont expanding our pipeline and also at the same time diversifying our community. What the early analysis of this program would show a significant reduction of cost and shifting away from traveler expense. It would be a three year commitment for those individuals coming into the US and Vermont specifically. And we're working with companies that have done this all over the US it's just more unique for us to be exploring that today but we see that as an opportunity here at CVMC. And then probably the area I wanna focus the most is the programs we've had growing talent locally through our nursing career pathway programs. So our LNA programs are strong and running. We've run four cohorts of LNAs in the last six months. We streamlined that program to two weeks. We have a lot of churn in our LNA employees. And again, bringing LNAs on board reduces our reliance on travelers. The piece that I probably wanna highlight the most is our LPN program which we launched prior to the pandemic. The first cohort was launched in 2019 with a strong partnership between community colleges Vermont and Vermont Technical College. These employees who are LNAs or MAs here at CVMC are screened and applied for this program. And if they're accepted, they're supported in completing the program in an 11 month cycle. Our own staff serve as faculty for this program whether they're BSN, baccalaureate or doctoral prepared nurses. They all support the program which has always been a challenge for nursing programs around the state of Vermont is the lack of faculty. They work 48 hours. They have 12 hours of paid study time and work life balance time. And their program starts Friday afternoons. They do the program on Saturday and Sunday. All those classes are offered here on site and that transportation was identified as a barrier for these individuals. And the first class graduated in June with 13 LPNs, which in another month will get us out of the traveler business at our Woodridge rehab facility. VTC recently shared that they're actually getting calls to their organization asking how they can students can enroll in the CVMC program, which is wonderful to hear. And of course they tell them they first have to be an employee at CVMC. So the good news is we actually have gotten a few folks that have come through that channel looking for employment specific to CVMC because we offer that program. And obviously we're trying to replicate that across the network. We also are now offering an RN program which is a graduated program from the LPNs being able to move on to the RN program. That just launched this week. And for the LPN graduates are now part of that program. So I'll pause there and hand it over to Tom for Porter's update. Chair Mullen, directors and staff, Mr. Fisher and Mr. Peesh, thank you for considering the fiscal year 22 budget of Porter Hospital. My name is Tom Thompson. I'm privileged to serve as the president and chief operating officer for Porter. A year ago at this time I was presenting this budget with Jen Bertrand as an interim president. I've obviously since accepted the role on a permanent basis. And I just want to let you know that a key factor in that decision for my part was the health networks focus on high value care and commitment to how care is delivered or changing the nature of how care is delivered and funded in our state. I'm joined today by new Porter CFO Scott Como. Scott has significant healthcare and private industry finance experience including 12 years with the university of Vermont Medical Center's medical group. A quality I very much appreciate Scott is his perspective of finance as a means to an end in supporting our mission. And he's a great partner with our team here to help advance that end. I would also like to recognize new medical center, CFO Judy Peek Lee, who was serving as our interim CFO during the budget preparation. So I'd like to take a little bit of a different twist in our presentation. Tom, your video isn't coming through. At least it isn't for me. I don't know if your camera's up there. There's your smiling face. Thank you. Thank you. I won't start over. Bless you. Chair Mullins or Steve, this technology thing, it is infectious. So again, thank you, John. We'll take a little bit of a different twist in our presentation today to highlight how Porter's plans advance a focus on high value care in our market and as a member of the UVM Health Network. So for just to recall a little bit more about Porter, we consist of a series of primary and specialty care clinics and post-acute and long-term care services in addition to the acute care and swing bed services of Porter Hospital. This care continuum obviously presents a very effective platform to support high value care. And I do, if you would, Jen, flip the page for me or flip the screen. On your screen is our strategy map. Its goals and objectives are designed to advance the Institute for Healthcare Improvements, triple aim, as well as a fourth aim to provide for a fulfilling work environment. All work within this plan is designed to lead to one or more of those four ends. And while events of the past year have caused us to moderate our plan's expectations a little bit, I would like to highlight some of the areas of progress that have, particularly have high value care impact in our plan. So this past year, one of those is that we've moved away from a leadership model that was organized by site of service to an integrated model across our care continuum that features physician and administrative dyads and triads working in a team-based leadership approach. This group is actively pursuing priorities to integrate care and work processes across our continuum. We also started our high reliability journey by training leaders in improvement science, creating process improvement expectations within each department, and recently recruiting a new director of quality safety and performance improvement to help us advance the safety culture and process improvement approaches in our work. We are redesigning our primary care clinics to operate in what many refer to as a team-based care approach with a focus on a blend of professional roles working at the height of their credential to deliver the right care at the right time and at the right cost. And as Dr. Brumsted indicated in some of the opening conversation, we have conducted a survey of our organization to understand perceptions of diversity, equity and inclusion issues. Results have been shared in dialogue with all departments across the organization. Our DEI council has been very active in implementing strategies affecting language access, signage policies and organizational communications. And a last thing I'd like to highlight on this slide is our work with community engagement strategies, including intentional collaborations with community agencies and efforts to engage community members in our work and in our mission. Jen, could you go to the next page please? Okay, so we have several strategic advantages available to us to lever and some challenges we need to overcome to be successful in our plans. And I'm gonna start with dedicated staff which have clearly stepped up tremendously through the entire COVID 1.0 experience as well as the recent weeks and months of persistent high patient activity. We have a great community as far as perceptions and engagement with Porter as a treasured community asset. And I think as importantly, we have an atmosphere in our community and area where we have several really high quality agencies that are collaborators in our mission. The UVM Health Network relationship is key in our strategy. It brings scale, unique expertise, support for care transitions, provider resources, shared services for technical support that we could not provide on our own. And last but certainly not least is EPIC. As was mentioned earlier, we go live with wave two of the EPIC investment here in the next couple of months. And there is a lot of activity toward our preparation and our ongoing optimization of that tool to change how care is delivered, both at Porter and across the network. We do have a number of challenges in our plan. Also a numbers one, two and three seem to be workforce shortages. And then it's again, it's a repetitive theme. Right now we're at 150% of budget on agency support and we are significantly past all other previous years tie water marks in that need for support. We have managers who are routinely staffing shifts. And I think probably what keeps me up most at night is a concern that our organization's compensation is be low market in a variety of areas and concern whether or not our budget that we have put forward can adequately address the needs that we have to keep up. A second challenge also an opportunity, our capital needs and funding, as one of the previous slides indicates we have ticked over 15 years in our average age of plant. And this year we'll be putting in place, hopefully some progress on our master facilities plan and investment in some of our areas where we want to better meet community need that of course will however place pressure on cash levels and margin pressures as we make those investments. To go along a common theme here, patient access constraints. I'll take a little bit of a different twist in that our recently completed community health needs assessment did cite affordability issues as one of the top three concerns expressed in the assessment process. At Porter, we have significant primary care access concerns and are looking both at traditional models as well as alternative models to pick up the slack and being able to introduce new folks to our practices and starting care relationships with us. The network here has also been of tremendous value in extending specialty support and outreach relationships to ensure local access to care. The capacity issues are highlighted by again, persistent high volumes, higher acuties, longer length of stay, mental health folks and mental health crises. And as Dr. Lepler mentioned, the dispositioning issues that we face across our health system within the network across our state, across our country, finding the right place for folks to receive care. At Porter, one of our additional challenges are facilities that are appropriate to accommodate these types of care volumes. Several of our facilities are quite dated and outmoded for the types of care we deliver today. In the last area, I'd like to say it is a challenge and an opportunity also our care inequities. And I think it starts, the challenge part starts with not knowing what we don't know. I think we have a lot to learn about those who are underserved and best means to reach them. Progress, however, is an organizational imperative. And we have been doing great work to date to start addressing some of the issues of the marginalized. Jennifer, you wanna flip the page? I would like to conclude with some critical success factors for our plan success. We have a very ambitious plan, even if it's had to be moderated a little bit this year because of a lot of other activities, our focus is on the IHI's triple aim and to realize those outcomes in a fulfilling work environment. I would cite some of the items on this slide as critical to our success. First is that we accept the responsibility and obligation to be a market leader as both a large employer and as a critical community resource. We are organized and are implementing priority plans to break down system barriers, to optimizing work and care integration, and thus advance a high value strategy. We recognize that Porter needs to be a provider of choice for Addison County residents for that care, which is clinically appropriate in our setting. Our plan focuses on improving access through value added programming and new service development to achieve this end. A role model of mine once said that progress consists of several small steps and an occasional great stride. Epic is a once in an organizational lifetime opportunity to revolutionize care locally and regionally for Porter and within our health network. We believe that continuous quality improvement investment leading to high reliability in our work is a required path for sustainability and high value. We are making those investments and setting those priorities. The needed capital investments I mentioned earlier, we are hoping to begin that work with our master facility plan this coming year to support both our work and care environments and address community need. As mentioned earlier, this is both opportunity and challenge for our organization. Finally, building on our community engagement. Our community engagement is pivotal in our plan, both in maintaining ongoing dialogue with our communities and in programmatic relationships with organizations of like mission, as I mentioned earlier. In sum, the budget proposal that we have put forward is our best effort under difficult planning circumstances. We appreciate your receptiveness to our approach and we look forward to updating you as our work pencils over the year. So thank you very much. Thanks, Tom. Strong work. Next slide, Jen. So we hope that the data and analysis that we've presented today has been transparent, accurate and in the spirit of collaboration. These are four points that I wanna highlight about the three affiliate budgets. First, we believe our net patient revenue growth is below national growth and within the 3.5% guidance when treated as a total cost of care per capita assessment. Second, most of our expenses are outside of the control of Vermont, of our network and of the Green Mountain Care Board. You've heard an awful lot this morning about workforce and the pressures that we're feeling in the workforce area and we are competing in a national marketplace for talent and that is just a fact of healthcare in 2021. Next, our commercial rate increase only covers the cost of expense inflation. And last, we think we've done a good job this morning of showing that we are efficient when compared to national benchmarks. We look forward to having conversations with the board and the staff about that. Next slide, please. This is just a picture. We included this in our narrative last year and this year of a breakdown of the total expense growth of the three affiliates combined and just how much salaries and fringe and pharmaceuticals and provider tax comprise those increases. You can see here that 3.9% of the 6.1 is an increase in salaries and fringe. And that goes back to our point that we're competing in a national marketplace in an incredibly dysfunctional labor market where we are seeing expenses rise faster than anyone would have thought a year ago. Next slide, Jen. So I wanna orient everyone to the next three slides. They're a breakdown of UVMMC, CVMC, and Porter Medical Center's volume as seen through billing when compared to a 2022 budgeted monthly average. One weakness of these three charts is that we did not seasonally adjust the 2022 budgeted monthly averages. It is a straight average. We use these same charts when presenting to the rating agencies because if you go back and look at October, November, December and January of 2020 and 21, you'll see that we presented to the rating agencies in March and we basically only had red to show them. And we were trying to figure out where volume would go by basically now. We thought this would be helpful to the Green Mountain Care Board and the staff of the Green Mountain Care Board to understand the volume assumptions in our budget and the volume trends that we're experiencing that we've talked about this morning. As far as how we construct our budgets, we construct them on a conservative volume basis. We do that because to do that in any other way, meaning in a more liberal way, we would actually commit to expenses that we would not be able to reel back in. And so each line of this is done carefully beginning in March. For everyone listening, if you haven't thought through the timing of this, we do our budgets from the bottom up in March and April and they're done in May so that they can make it through our boards and be to the Green Mountain Care Board by July 1st. And so that's what Mark was talking about earlier with looking at the October through January. And you can see here that October through January in 20 and in 21, was no map to estimating the budget in the upcoming fiscal year. And so we had to do a bunch of adjustments to try to figure that out. And that's why we've said budgeting through the pandemic has been so hard and it's hard to know if you're getting it 100% accurate. And so we've done our best, we stand behind our budgets, but these are the inputs. And so when we say that the ED is very busy at UVM Medical Center, second line down on the left, you come across we're at 115% in June. That's just an example of what we're seeing. And if you go back to the first wave of the pandemic, which isn't shown here or the second wave of the pandemic, you can see that folks just didn't go to the ED. This graphically tells the story. If you have questions on these, we can go into detail, but I'm just gonna call out a few things. Please go to the next slide, Jen. So this is Central Vermont Medical Center. One point I'd make is if you come down three lines on the left, you'll see inpatient births in June. People have asked if there's gonna be a mini baby boom from the pandemic. You can see 152% of projected volume that may be pointing to an answer. We'll see how the statistics play out, but it's just interesting to see this at this level. You can also see that inpatient discharges are above where we're projecting for 2022 by the month, but there's a lot of red on this chart. And so volume assumptions here are critical to making sure that we make our budget for CVMC. Next slide, Jen. So this is Porter Medical Center. This does also include Helen Porter. If you come down on the left to inpatient days SNF, you can see the volumes there. Just to be clear, we include all of these when we do our analysis. I would also call out the ED visits for Porter at 107% of the projected FY22 budget, just to also show just how busy we are in the thing that we call the aftershock, which when we wrote our narrative, we thought we might be through by now and we were wrong. Next slide, Jen. Now I'd like to talk a little bit about what we're seeing in terms of population and demographics. BRG did some good work for the Green Mountain Care Board and based it upon, I believe, the 2019 census estimate. We decided to take a look at that and hire some outside folks and really dive into where we think this is going for us because I want to be clear. We are not comfortable with where we are at in terms of satisfying the volumes that we're seeing at this point. I believe Dr. Leffler explained that very well and we were trying to understand where the population is going. So just a few key things to think about. The Burlington Metropolitan Statistical Area is gonna grow by 16% in the next 20 years and that is from the 2019 projected. So we believe it'll even be faster than that. So we think even this is now a conservative estimate. The Medicare eligible population will more than double and Medicaid will grow by 12%. Next slide, Jen. And so this to me is the single most important slide in this whole deck because I asked you earlier when we were talking to really focus on staffing, that staffing was the thing other than approving our budget I wanted you to take away from this. And this is why this is a problem that we need to partner to solve. We, the UVM Health Network, need to partner with the Green Mountain Care Board and with the state of Vermont to be able to have the people and the facilities we need to care for this population. What's gonna happen to the Medicare population in the next 20 years cannot be better explained than this chart. And again, this is a conservative estimate. We've got to begin to get ready now with pace and a sense of urgency or things will only grow worse over time. So again, we need help and we need your best minds on this and we need partnership because this is truly something that we need to face together. Next slide, Jen. We've talked about our people. This is the projects that we've talked about publicly and written to you about, these are. We do not believe that we'll be successful over the next 20 years if we do not invest in both our people and projects. I'm not gonna go into detail on every single one of these we've mentioned them throughout the presentation. We can answer questions once we get to that. Next slide, Jen. I think we should have probably kept count on how many times we've mentioned access being an issue in this part of the presentation because I think it's obvious that we're all taking it very seriously. I just wanna call out a couple of things. We cannot address access without our budget and without a margin. Those things can't happen without happening together and we can't address our facilities without partnership with the state and with our regulator. And so when you look at the bottom bullet here that we are actively recruiting over 75 physicians across our affiliates in Vermont. That should explain physicians if that's the only problem we had. So in order to address access, again, we need people and we need facilities and we need a margin to take care of both of them. Next slide, Jen. So as I said, we put together our budget from a bottom up process in March and it's approved in early May. So there's always risks, meaning we're making big assumptions on the future. So let me go through some that we see and I really frankly like to hear any that you see because anything that'll help us get the ship to port so to speak. First, obviously if we don't receive the commercial rate we've requested that's a risk to our budget. Second, since we put our budget together the topic in the Wall Street Journal in New York Times almost every day has been is the inflation that we're seeing transitory or is it sticking around? And I'm not an economist so I'm not gonna weigh in on that but it seems like it's a little more sticky at least this month maybe people thought so that could impact us. Medicaid and Medicare payment policies. If Medicaid and Medicare do not keep up with inflation it continues the pressure that we put on the commercial payer. This is the cost shift. You've spent a lot of time talking about it as a board. This is a stress to our budget. This is a stress to the commercial payers. Next, if the ACO program rate that is allowed with the federal government under Medicare or if Medicaid were to change its policies and limit that in any way that would be a risk. The next bullet, who knows what's next with COVID? There's been a new crisis rolling right along and so we need to be ready and we are but it may impact our budget. We have not made decisions based on money when dealing with COVID. An example would be vaccinations. John's point on vaccinations was if we get paid or don't get paid, he did not care. He wanted us to vaccinate everybody that wanted a vaccination and we held to that. And obviously we then worked it out with the state and federal government but we were head down trying to get that accomplished. Next, our outpatient pharmacy revenue may be overstated and that is due to the ever-changing and shifting sands of the 340B program. Last, workforce challenges. I think we've said enough about that today. And finally, Epic. Epic implementations at our two non-academic medical center affiliates in Vermont. The budgets could be at risk if we poorly implement and perform once Epic goes live. That's a real risk. I will tell you that the benefits outweigh that risk to the good points that Tom Thompson made about the incredible moment we will have once we get everyone up on Epic but that is a risk to the budget. Next slide. John, do you wanna jump in here? Go ahead and take this out first shot and then I'll jump in and I have a couple of summary comments. Thanks. Yeah, so the great thing about these hearings is we get to talk about more things than just the budget and we get to think through things that are really important to educate Vermonters about that aren't just truly financial. But at the end of the day, this is a budget hearing where we're asking you to approve what we've proposed. And so here's our ask. We have a budget of all of our three Vermont affiliates combined that's about $1.8 billion as proposed for FY22. And we need the NPR and the commercial rates that we've requested to accomplish the mission that we've set out for FY22. We hope you're comforted by the fact that we are not asking for anything more then or anything less than what we need to cover our expenses. Final point, we need the margin to be able to invest, to invest in our people and to be able to invest in our facilities. Thank you, John. Thanks, Al. Our current times, I said they were complex. Sometimes they characterized them as interesting. They really have been put in the context of crises. We have a crisis with a worldwide pandemic that just keeps coming and coming and coming back in various forms. In our state, we have a crisis with mental health access and I don't yell fire in a crowded movie theater. It's just not what I do, but there's no way to categorize what's going on with mental health access in this state other than a crisis. You combine the two and we have a crisis in access and actually in talking with state leaders workforce has been put into the mix as a crisis. And I can tell you, I'll give you a little vignette of what's going on around our piece of the universe. Way back with the first wave of crisis, we had an every afternoon call that had leaders from around the network and then around the region that got together to brainstorm solutions and to give situation representatives of where we were. And we've gone back and forth on that model. We're back. And it's not just for COVID, it's the constellation of things that we're facing. And we've had three or four of these meetings now and they are remarkable happenings. The things that are being discussed by our leaders are just mind boggling. And I would invite any of the Green Mountain Care Board members, if you wanna attend one of those meetings, we're totally transparent, you can do so.  I've obviously been around this block for decades and decades and decades and I'm impacted by those meetings.   Steve said, you know, the Academic Medical Center levels our access and our capacity on a moment to moment and day to day basis. You know, this is just incredible time, interesting time, a time of crisis. And the way we get through that is we all pull together. So what I said right at the beginning, we can't do this alone. We have the people and the experts, if we have the resources and the ability to reinvest in our organization to get through the near term and to be sustainable in the long term. And that's how all of this ties together. It's not hyperbole and it's not crisis. It's a crying wolf or fire in a crowded movie theater. And again, anybody that wants to experience exactly what we're talking about, I'll invite you. Elle runs the meeting as our Chief Operator and I'm happy to have you listen in if you wanna experience what it's like on the front lines today. So with that, Chair Mullen, I'll turn it over to you for the rest of the time. Decide how you wanna administer the questioning. And again, I can serve as a MC unless one of the board members, you wanna direct your question. Of course you can do that. Otherwise I'll try and direct where the question can be best answered. Thanks. Thank you, John. And thank you for the whole team, for the presentation, very thorough work. Just wanna, before I start to go to questions, I just wanna respond to Elle's point that you really need willing partners to solve the workforce issue. And I refer back to 2018 when I testified in the legislature and called it a crisis for the healthcare system and people thought I was being melodramatic at the time. And here we are today. And clearly it is a crisis. And it's something that not only the state of Vermont, but our entire education system has to become involved with in order for you to have success. This isn't something that anyone can accomplish on their own and we'll have to all work through this together. I have had already a request for another bio break. I've asked that person to please wait until noon. I will be very prompt at noon to break for lunch. I'll even interfere with the questioning of a board member at that time if that occurs. And to start the questioning off, I'm going to ask our staff to ask some questions that they have and then I'm gonna start with board member Maureen Youssefer. So Patrick Rooney. Thank you, Mr. Chair. Joanne for the record, this is Patrick Rooney. Title is director of health systems finances for the Green Mountain Care Board. I would also like to thank the UVM health network leadership for their time today and the opportunity to ask some questions. And also I would like to reiterate that the staff have greatly appreciated the dialogue that we've had with UVM health network leadership outside of this budget cycle over the past several months. It's been very informative to discuss some of the complexities that are facing your organizations throughout this year and with the ongoing rise of variants with COVID and some of the other complications that have arisen that impact your providers throughout your network. So thank you very much for that opportunity. And Dr. Bromstad, I'll meet your request to push my questions through you and for you and your staff to leadership to respond to. I apologize for the lack of organization here. I've been jotting these down as we go through the presentation this morning. So from a topic's perspective, I might jump around a little bit. Okay, thank you. With that, Dr. Bromstad, you had spoken earlier about bearing the fruits of integration and certainly it takes several years to integrate or affiliate a standalone organization into a network. For example, IT systems, alignments, supply chain, administrative functions, et cetera. That said, you have several people on this hearing today who can offer some valuable perspectives. Ms. Newton spoke to some of these questions, some of my questions earlier, but looking at fiscal year 22 and beyond, what are some of the remaining challenges and opportunities that exist for management to bring the Central Vermont Medical Center to a financially stable and financially profitable state of operation on a year-to-year basis? Just to generalize that great question, Patrick, we're just now starting to realize the true benefits of what you said, bringing all the organizations around on common systems, processes, IT platforms, and we're just starting to see the spend on administrative shared services to go over the top. And further questioning, Rick Benson, I'm sure can provide value as to how that's gonna rapidly accelerate in a good direction going forward. Specific to Central Vermont, I'd like to start with you, Al, because you can put it into the general perspective of all of our entities, and then, Anna, you can provide some specifics. So Patrick, how are you? It's nice to meet you, even if it's over teams. Pleasure, yes. Absolutely. So CVMC, if you remember the margin chart that I can't ever forget has not had a positive margin in several years. And so the good question you're asking is, when do we see that turning around and how do we see that turning around? Well, one big giant step is bringing together all of the technology platforms that we have that we're implementing so that we will be able to have eyes into everything that's happening in real time and also better manage the rev cycle and accounting systems of CVMC. So specifically, Epic. I'm gonna say this, I think Anna mentioned it last year or in another hearing, but the OR at CVMC runs on paper, just as an example. That's not a goal of any health system. And so that's something that Epic will change and that obviously we've done all the work with Epic and all of the process work that Anna talked about to fix that. But that's just a glaring example of how technology will bring systemness and transparency within our own network as to how we're doing. And so I'm answering your question though, specifically to the question about what I think of a shared services. We can also talk about volumes and changes to the operation there if you wanna have that conversation as well. Anna, did you wanna add anything to what I just said? And just underscoring what you've already mentioned, Al, you know, it's vitally important in today's world that we have information to drive our operations and CVMC has been lacking in that regard for a number of years, which makes it challenging to pivot to address concerns. So Epic is going to be a huge lift for us. And the fact that our perioperative service line is entirely on paper in 2021 is pretty extraordinary for a healthcare system. And I think that just underscores the challenges we have here. Manual is my least favorite one. Epic will be a huge boom in that area. And so I think for us that systematizing by leveraging the variety of electronic advances, work day being one, Premiere is another that we've implemented and now the last one being Epic is gonna be critical to our realizing a positive margin. That along with operationalizing and improving the efficiency of our operations, Periop is a good example of that. So increasing the productivity of our perioperative services. And again, this is a great example. We're coming together as a network is a wonderful thing. So UVMMC has some challenges. We've been able to bring some of those volumes here and keep care local. And still make sure that we're optimizing a pretty invested area like Periop. So that's just a small example of we're coming together as a network is advantageous for us. I'll just pause there and see if that answered your question, Patrick. Yes, it does. As Mr. Gobi noted that past margin has been a bit of a concern for us as we look at the month to month operations of CVMC. So it's nice to have a clearer picture of where you expect to capitalize on some of those improvements. Certainly anything running on paper these days is a bit of a concern. So glad to hear that operationalizing that hospital should provide some improvements and efficiencies to help you suppress cost growth and maximize margin. So thank you. I appreciate the answer. My next question, Dr. Brumstead, Mr. Gobi, you discussed the expense controls undertaken by the network to counteract the financial pressures brought on by revenue reductions largely related to COVID. When I read your most recent Fitch analysis in March of 21 for your network hospital's financial state of being they use your efforts to control costs, 52 million in expenses, $45 million in capital as part of their justification for giving you a stable outlook and thus maintaining your A plus rating. So will any portion of those non-capital expense controls be permanent in nature for the University of Vermont Health Network? Rick, do you wanna pitch that one first and then, Al, if you have something to add? Pretty much all of those things, we put it, hi, Patrick, by the way. Pretty much all of those things that we put into place are still in place today. I think that the key thing that we, and we put this in place even before the pandemic was very tight position review committees at all of the organizations where we're truly making sure that we have the work and the volume to support any either replacements or position additions has been, that was something that was put in place before the pandemic that obviously hasn't gone away. The other really is on the shared service part of the organization. And when I say shared service, that's all administrative services. So HR, payroll, revenue cycle, all the non-clinical services that we provide, that we, even with the fact that we're not yet all on the same systems, we've seen that that is, and that's something that we've been at for a while. We're continuing to make progress in that space and we haven't peeled back anything that we've done in that area either that the rating agencies saw when they reviewed us back then. And once we are on the same systems, that's just gonna accelerate the ability not only to maintain or reduce costs, but also to improve performance in those areas so that we maximize the, whether it's having a very efficient payroll department, a very efficient accounting department in terms of the quality and accuracy of those services. None of that has gone away since the rating agencies reviewed us. The capital spend, Al, do you wanna just talk a bit about how we're loosening the chains on that? Yeah, so before I do that, John, I do wanna comment on one part that did go away. And that is we did reduce the pay of leadership. We did e