I'm ready whenever everyone else is. Okay, so at this point, I'm going to turn it over to Mike Fisher to ask questions of UVM. Mike. Thank you, Chair Mullen. Happy to be here and happy to have been here all morning to listen to the presentations and I will join in the expression of appreciation for the excellent work of the UVM Health Network hospitals as well as all providers. And just because it's on my mind, I think I'll just say out loud that I don't, because it's been set up, sometimes it feels a little bit like a dichotomy. I think it's worth saying out loud that I truly believe it's possible to be fully in support of the heroic efforts of our healthcare providers and to believe in strong regulation and the efforts to look at the budgets and question the budgets and ask for improvements. I don't believe that those are in conflict. Let me start by, I want to start by expressing some appreciation between last year and this year, UVM Health Network and my office have engaged on improving their financial assistance policy, plain language, UVM stepped up to the plate and engaged in a process that I think was good and helpful and I think there's been some real improvements. And I also want to appreciate John Bromstead's statement from earlier about the recognition about racial disparities and recognize that we all have a lot of work to do and sort of call on Mr. Bromstead. We would be happy to join in you. I think we're looking at our own organization with this question of how do we have practices? All of us I think need to look at our practices critically to evaluate where are we in patterns that advance that continue racial, the practices that contribute to racial disparities and I think that we all have some work to do. So I appreciate the recognition of that. So I wanted to ask Dr. Leffler on slide 25, I don't know exactly who's on, but he recognized the many lines of service where there were losses and that was an impressive list and I wanted to just ask whether he was able to or anyone was able to provide any insight as to the other side of the equation, the lines of service where there are profits. So Mike, this is Steve Leffler, thanks for asking. And first off, I would just acknowledge that UVM Health Network is proud to discuss and explain our budget as well. We feel strongly that the budget we're presenting is the budget necessary to care for her monitors and be strong for our communities. So we are proud and appreciative to have the opportunity. In terms of areas of profit, most of it is really around scheduled procedures. That's really where the opportunity is and that's why services like elective care, when you stop those or eliminate those, has such a huge impact on all hospital budgets, including the medical center. So what I would say is that if you look at areas of elective surgeries and many inpatient surgeries, that's really where most of our margin comes from. And there are some other examples. I'm sure Rick, if you want to, could give other ones, but if you think about cardiac surgery, total joint replacements, a lot of orthopedic procedures, colonoscopies, things like that are really where our margin comes from. So if I could just jump in for a second because Dr. Holmes has kept us on track to be pretty pristine with our definitions and our terminology. Profits are in a for-profit world and go into a shareholders pocket. These services create a margin where the revenue that comes in to cover them is greater than the expenses to provide them. And those dollars are then redistributed either to cover these services or year over year to cover improvements in programs, people, infrastructure. Yeah, I'm happy to be called out on that term. I knew I was using it. I merely mean a line where you bring in more money than you spend providing it. That's all I mean. I wasn't implying that you had shareholders, but I was meaning that there are lines where you bring in more money than you expend. Yes, thank you. I think that's what the term profit means, but that's okay. Sir plus, try sir plus. Awesome. I was interested in Todd Keating's description of some surprises around expectations around the money around self-pay and bad debt and the discussion, I think in written comments around some theory that maybe this had to do with the extra UI and stimulus monies that came to Vermont families. It's not at all surprising to me. Well, that's interesting to me. I haven't heard other hospitals describe that. And I wondered whether the other hospitals represented here saw anything similar. Hey, Mike. Can you hold questions for the other two till when we call on you for that and just focus on UVM Burlington at this point? I sure can. Thanks. Well, then let me just ask UVM that question. So we haven't seen any kind of impact in terms of an increase in bad debt and charity yet. Mike, this is Rick Vincent. And a part of that too is the fact that we held, as Todd mentioned, we've held our collection activities at bay for a period of time. And so, we've made some estimates in our financial statements that we expect that that same rate will be somewhat present as that activity ramps up. But for now, we haven't seen a major deterioration on bad charities. So follow up to that. Given the pretty tremendous loss of income in Vermont families, I wonder whether you've done any, and given the discussion about how you set bad debt and free care expectations year to year, and just ask you to reflect whether you think there's any risk in 21, given the economic pressures on Vermont families? Yeah, there likely is a risk in 21 that our assumptions there may not materialize in terms of those two. We've certainly, and I think we might have answered this in one of the questions that you posed. I mean, we, given the position that we're in, we certainly have taken typically our charity policy doesn't allow for kind of immediate situations to come into play. But if somebody didn't qualify, for example, prior to COVID, and that now does qualify, we've re-looked at those applications and have qualified people for financial assistance that maybe hadn't qualified before COVID. So there is definitely some potential that that could grow next year, but we'll have to wait and see. So I think I had a few follow-up questions from board members. I guess a telehealth follow-up question. I was interested in that description of the dynamic where people present for a telehealth visit and then called back for an in-person visit and was just thinking about the financial impacts on multiple levels of that and wonder how often that happens. I don't expect anyone to have a direct answer about that, but it's a curiosity of mine. If anyone could shed any light on that, I'd be curious. So Mike, I can't tell you the percentage. What I can tell you, the dermatology example was a family member and they were very happy about it because they knew from the initial, when the dermatologists looked at what did the telehealth visit with them, that it was important to go in and be seen and have something done. And I would assume the opposite's also true that most of the time or the majority, the dermatologists say, don't worry about that, you're all set and they don't have to travel to the office or anything else. So my guess would be it's at best a balance, but I bet it's positive on the patient side. Yeah, I'm not suggesting otherwise. I'm just thinking through the financial aspects of that, whether two visits are built for and how often that happens, that was it. On the, I think, Steve is saying with you, Steve, on the volume questions from member homes, am I to take it, let me just say, I respect and understand UVM health networks decisions not to try and project what's going to happen with COVID. And I don't oppose that decision. I also think to not recognize it in 21 is sort of glaring as well. And so I realized you kind of probably can't win. I've just said you probably can't win, I recognize that. But I wonder whether your response to member homes about your volume suggests that you're projecting 100%. I would state it a little differently. We've spent a huge amount of time in what I would call the in-between time for COVID for us. So there's not much COVID here right now. We actually have no one in the hospital today with COVID preparing for the fall when COVID is back. And we expect to have anything from two or three cases and that can be mostly business as normal all the way up through. It hits Vermont in such a way that we really need to preserve our ventilators in our ICU beds. And we expect that to be, I won't say unlikely but a lower likely scenario. So we think in the future as COVID goes back into Vermont we will continue to do the surgeries and procedures and all the things people need. Like we do every other year when there's flu outbreaks and RSV and those things. And so we've really tried to build a model out to be able to be here for people. Will it be a hundred percent? It's hard to say that but that's really the model we built along with our clinical model of not stopping. And I don't even like the term elective because people who waited in the spring some of them suffered greatly for things they really wanted to get and we're very grateful when we were allowed to get their surgeries done. Hope that answers. Yeah, that's good. Maybe this one is just meant to be a statement. I just want to appreciate the line questioning that Member Youssefer had about efficiencies. I think that line of questioning and I think is really important. I think no system is as efficient as it can be. And so I appreciate that and I'm not going to add to it but I just wanted to recognize it. I wanted to, let me recognize that this is maybe a little bit of a pet peeve of mine and that I have an opportunity here to talk about a pattern of discussion about things like provider tax and cost shift. And as you all know, given my various roles in health policy have been on all sides of these questions. And I guess I just, when I hear providers talk about how difficult provider tax is, I want to ask, do you have proposals about other ways to fund 25% of Medicaid? And it's a rhetorical question. I'm not expecting an answer just to recognize that I understand how difficult the provider tax is. And I want to say the opposite side of that equation, wow, 25% of Medicaid is really significant. And I don't imagine anybody in this meeting would support a cut of that size in Medicaid. And if anybody wants to respond, I'm happy to. Well, Mr. Fisher, I mean, I apologize for myself and my team if we misspoke. I don't think anybody was talking about provider tax in a pejorative sense, it just is what it is and quite the opposite. It really is a driver why we should all together be working to keep Vermonters in Vermont. People just need to understand that for every $100 that is spent on healthcare out of this state, the state loses $12, $6 of tax and an equal drawdown from the federal government and agree with you. I wish 100% of the dollars went to support the Medicaid program and not other things. So if we misspoke, I apologize, we in no way think that provider tax, like any tax is something to dodge or be avoided. I'd like to keep those dollars in Vermont. Yeah, I don't think you misspoke. That's why I introduced this with my recognition of some pent up feeling about it. It's part of a bigger pattern that I just think needs to be said out loud. So thank you for that response. Lastly, I fully appreciate and understand your description of this year's increase as your request that we see it in a multi-year context and have seen and understand your arguments for that and that whole discussion. And even just accepting all of the assumptions built into that, here we are in end of August, 2020 in the middle of a pretty significant public health and economic crisis. And I would be remiss if I didn't ask out loud. In the context of this moment, given what Vermont families are dealing with in this moment, do you worry that whether Vermonters can afford the rate increase that you've asked for today? Of course we worry about it. That's why we characterize it as a balancing act every single year, every moment that we're working, we're looking at trying to improve efficiency. It's a basic reason why we're doing the hard work of creating the UBM health network to find all the efficiencies we can, it is as we've said in the budgets, incredibly complex. Personally, I've advocated right along that we get the increases that would cover our expense increases no more, no less than every single year that I've presented a budget and we haven't gotten that. If we had, we wouldn't be looking at this big jump and look at it over five years. It's under 4%. And so that really is sort of the cornerstone of our whole presentation. And it has been over the past several years, we're very concerned about affordability. But again, you've got to look at it over time, under 4% if you look at the five year average. Mr. Chair, that's my questions for the moment. Thank you, Mike. At this point, I'm gonna open it up for public. Excuse me, I'm gonna open it up for public comment and call on Jeff Thiemann. Thank you, Mr. Chair. I'll let you get a drink of water there. I just wanted to say that I appreciate the Green Mountain Care Board members who have expressed gratitude to hospitals during this budget cycle. As many of you have said, they all, every single one deserve credit for their thoughtful and careful and most importantly effective work on COVID-19. In the context of this particular hearing, I wanna add that the strength and the skill of our academic medical center and the broader health network was really absolutely vital for our collective success. Dr. Brumsted, Dr. Lefler and the Newton, Tom Thompson, all the leaders, doctors, nurses, supply chain people, IT engineers and others who helped manage this situation. They all deserve great credit. The issues weren't easy and they didn't offer any natural precedent from urgent PPE acquisition to processing the scientific and government advisories that were coming out and changing every minute. So I just wanna remind you how fortunate we really are in a small state to have a top ranked academic medical center that anchors for profit hospitals. We saw over the past few months just how important UVM Medical Center is, not just as our constant caregiver, but as a leader in public health, working to inform and coordinate our COVID response. I've never been so glad that we have every single hospital in Vermont, all of which are still working so closely together and so important and benefiting from the expertise and resources of both each other and UVMMC as they try to keep Vermonters safe and minimize our spread of infection. So that's really the point I wanted to make. I think our Vermont response would not have been what it was without our trusted and capable academic medical center in Burlington. Thank you. Thank you, Jeff. Other members of the public who wish to comment on the UVM Burlington budget? Oh, Matt. Go ahead. I'd like to comment on the comment. I'm assuming it's you, but Sunny needs you to say your name for the record. Oh, Dale Hackett. I'd like to comment on the comment about the $100 spent out of state where $6 is lost on federal money and $6 and taxes. Our state is small. We don't have every kind of specialty that is needed. If you have a rare disease like I do, you cringe when you hear comments like that because there is absolutely no way that I can even go to UVM. I can't even go to Dartmouth and get the specialty care for the kind of condition that I have. It takes Columbia Presbyterian in New York City, Pittsburgh. Those are the places for one of the conditions I have that have the knowledge on these conditions. What gets interesting is you can send somebody to a specialist like a neurologist and say, well, the dollars are kept in state and they're seeing a neurologist. That's not the same thing as going to Columbia Presbyterian where you may have a neurologist that all they do is see rare diseases all day long. So I just want to really pull back on that one. I get it. We want to keep dollars in the state but not at the risk of putting consumers like at risk and the comments. Sure. It's a very good comment, Dale. And I'm sure not to try to put words in Dr. Brumsted's mouth, but I'm sure what he was trying to say is those services that can appropriately be done in Vermont should be done. And that just makes common sense because we would much rather have a doctor and a nurse and a business office manager employed here than in Pittsburgh. But we also understand that we also can't do everything. So thank you, Dale. Thank you. Other public comment. Okay, I'm not hearing any. I'm going to switch over now to Central Vermont Medical Center. And we will start the board questioning with board member, Yusuf or Maureen. Thanks. First, should be glad to hear it. Most of my questions were already answered because I asked them about the whole network. But just one question on the NPR growth that you're forecasting for Central Vermont. Now, I just want to point out a couple of things that Central Vermont of the 14 hospitals that are out there, Central Vermont is asking for the largest increase from 20 budget to 21 budget and the largest increase from 20 projection to 21 budget. So obviously those are just two benchmarks looking at that. But, and the other component of it is we're also saying that we're not exceeding 100% in volume. So it isn't really because we're pulling in what was missed for COVID in 19 or in 20 is coming back in 21 to exceed your normal volume. At least I haven't heard that. So just make me feel comfortable that you're actually going to hit these numbers because the past two years prior to 2018 and 19 you missed your top line NPR compared to budget. So we kind of go through this whole thing every year and we talk about going above the cap and things like this and then the past two years in a row you've missed a budget. And now you're asking for the largest increase of all the hospitals in the two areas that I've stated. So just make me feel comfortable A that you're going to hit the number and B that you weren't getting the largest increase year over year. So Maureen, this is Todd Keating, it's a great question. So, you know, as Anna mentioned before and everything one of the things that the hospital is challenged by is really it's up and down inpatient volumes. And so at times it'd be very difficult to predict what's happening. But the good news is that there's an ambulatory strategy that's being developed and put in play where you're going to see an enhanced productivity from the physicians at a time where we saw some inpatient growth that became that was organic prior to COVID-19. So we think that the two coupled together will actually occur on the volume side, particularly on the inpatient side and on the part B side with the physicians. One of the things that's built into the number that's not necessarily all right as well is we are taking the revenue cycle under the control, let's say now of the network and such. And as we're going into that, we are finding opportunities to enhance documentation, coding, overall billing and collection performance of what have you. And so a lot of that is going to also enhance the revenue. And the rate for the most part is similar to the conversation we had earlier with regard to the times where the rate wasn't where it needed to be. You saw the example of oncology drugs versus the total pharmaceutical costs. So there is a big hit within that pharmaceutical area because not only is it inflation and stuff, but now when you look at the oncology drugs and the revenue being generated, it's not sufficient to offset it. Okay, and then usually on this one, my comment is really related to your expenses are going up higher than that even. And should you miss the top line, it just puts more jeopardy on the bottom line because the expenses aren't able to be cut. So it's really there trying to look at making sure your top line number is realistic. Because I do see that you were ahead through February when most of the hospitals were not. And that would be a couple points of it. Your commercial ask or your rate changes are a couple points, but then that difference, which is really coming to more unique patients and the pharmaceutical change, whether that's all gonna happen would be the challenge because your expenses are up significantly as well, which we've gone through, equalling what's your 20 plus million that you're going up on the top line. So to your point, the other side of the equation naturally is expenses. And so as we were going into, well, we didn't know we were going into COVID, but we were looking at the expense variances that were generated prior to COVID. We realized that there was a significant challenge with regard to the labor component of the, let's say, not only the budget, but the actual performance year to date through February. So as we went through COVID, one of the lessons learned was that as a senior leadership team and stuff, we needed to review FTEs on a regular basis. Rick made a little bit of a joke about, he went on vacation and he's worried about how many new FTEs showed up during his time off and everything. The senior leadership group took the COVID experience to really do an exercise in improved expense management, not only on the labor side of things, but on the non-labor side of things as well. And during the three and a half, four month period, actually performed under budget to the point where the negative variance for the guard to expenses is now a positive variance. And so making progress and continuing to make progress there. So I think it's a combination of the two. And to your point, not everything is 100% predictable stuff, but for what we saw this year with the guard to expense management trending and then the volume trending. And now what I'll say is enhanced performance within revenue cycle, that we believe that we have much more confidence in hitting this number than we did in the prior year. Okay, thanks. And that's all I have. Thank you. Thank you, Maureen. Next is member Holmes, Jessica. Okay. Well, I think Maureen took care of a couple of my questions. I just will say I share similar concerns and I hope that your confidence is well placed. I really do hope that, you know, through expense management and productivity increases that you will make that top line. So two quick questions, I guess. One is, I think I heard you say that the assumption about the Medicare rate increase was that 0.85%, is that right? Yeah, 0.85 for CVMC, yep. For CVMC, okay. So I'm gonna make sure I had that, right? And then actually my last question is a question I've asked a couple, at least one other hospital. Recently, there's been lots of talk about consolidation and its impact in Vermont. And so as a hospital that's chosen to affiliate, obviously with the UVM Health Network, I'm wondering if it's possible for maybe Anna to talk a little bit about the impact affiliation has had on CVMC. What would the world look like for CVMC had they not affiliated? So thanks for that question, Jessica. I would say that had we not affiliated with the UVM Health Network, CVMC would be in an even more challenging position. So the opportunity to really pull resources from the network and that includes expertise from the network is huge. Both Todd and I are collaborating really well when it comes to things like when a key staff member transitions out of the organization, looking at the opportunity to consolidate versus just adding that position back in, which we've done with our director of revenue cycle. And we're benefiting from the expertise of the network revenue cycle in that shift. And that's just one small example, I think of the benefit that CVMC has gained. I would say the other benefit would be in some of the collaborative work we're doing in the clinical delivery optimization. So looking at where services are being offered, what type of services should be offered and making sure that our services are sized appropriately for the population that we're trying to serve. That's another wonderful opportunity. The other opportunity goes the other way. Because we're small, we can be a sort of alpha beta site for some innovation here at CVMC. A good example of that I think is the work we've done with standing up an LNA to LPN program, working with CCV and the Vermont Technical College. And that's made a significant impact on the number of travelers that we will need not only today, but in the future. So standing up the LNA program, standing up the LNA to LPN program will serve us well. So I think there's a lot of benefits to being part of this larger network. And clearly, Todd can speak to this as well. Some of the opportunities that come from being in a larger network where we would not have the buying power that we have as part of this larger network as it relates to medical surgical supplies, contracting, negotiations, those sorts of things. We simply could not have that kind of expertise or those types of investments in an organization of our size. So would you think that community members would view this as a positive having affiliated? I would say yes. And I think the other thing that's becoming even easier for people to see with our Epic Go Live in the fall was the seamlessness of the care delivery from a patient coming to CVMC and then if they need tertiary, quaternary care of the academic center being transferred up to Chittenden County to receive that care at UVMMC, they see that seamless transition coming back and forth. Another wonderful story that we had right after Go Live is we were actually caring for a child here that was receiving care in North Carolina and they were an Epic client. And so our physician was able to, through care everywhere in Epic, open up that individual's chart and seamlessly see what that child needed for care, the care that they had received in North Carolina and then in turn optimize the care here, which would have been absolutely unheard of had we not affiliated, we would never be able to afford a platform like Epic and an organization our size. Actually, it brings up one final question. I thought it was done, but I just remembered, I wanted to ask is the Epic Implementation complete at CVMC? It is not, the next round wave two that I mentioned briefly in my presentation will be the rest of our system being live on Epic. So in October, we went live in all of our practice divisions, all 23 practices and the revenue cycle on that side of the business. In spring of 21, we'll be going live on the acute care and all the rest of the enterprise for CVMC with the exception of Woodridge. Okay, I did catch that and I remember you said that. No problem. Let me just ask you. So then in some ways that brings up a little bit of even greater concern about the revenue. We know that when Epic Implementation happens it's just natural to have productivity losses. So have you factored in, in these NPR numbers, productivity losses associated with Epic Implementation in the spring? So Jessica, what we did is we kind of modeled it after what went on at the Medical Center. And because the timing of the implementation would give us the last six months to catch up on anything that we would let, let's say got hung up in the system that we should be able to recover within six months. Now, one of the benefits to going wave two is that a lot of the, let's say the issues that slowed down the first implementation wave one have been corrected. And so a lot of the pressure points that held up revenues or what have you in wave one won't be there for wave two. So the physicians are already up on it, okay? So that is not gonna be a challenge and everything. It's gonna be the hospital itself and how quickly they get on. But a lot of the challenges in the hospital performance, I'll say the Medical Center Performance in wave one have already been taken care of and such. That being said, we think six months is enough time that if there is some bumps and bruises in the beginning stuff that we'll be able to smooth them out with the payers and have it all remedied by the end of September 30th. Okay, thank you. That's all I have. Thank you. Thank you, Jessica. Next, we have board member Launch, Robin. Thank you. Thank you. And I wanted to just give you a shout out Anna because as you know, I live in central Vermont and while I'm fortunate to mostly not need medical care, I do have a physical therapist who's part of CVMC and he unsolicited not knowing what I do for work gave big props to your staff management and how people were given opportunities to be retrained and shifted into new roles as opposed to being furloughed. So I have a source from one of your employees who very much applauded how that was managed. So congratulations on that. Thank you. So shifting to these questions will not be surprising to you because I've been focusing on a number of the same areas in each with each hospital. So I wanted to hear a little bit more about your overall numbers of travelers and how that's going. It was great to hear about the LNA and LPN program and the success that you've had at Woodridge with reducing the travelers, but how's it going with other travelers in the hospital and what are those numbers look like? Sure. So for travelers year to date, we've used 16 FTEs of travelers and July, we were down to eight FTEs. So we essentially cut that in half and our goal is to get out of the traveler business as much as possible and some of these workforce improvement efforts that are underway we think are really gonna help us. The other thing we're looking at, which I didn't list as an opportunity earlier, but I'll mention now is we're also looking at improving the RN, LPN to RN program. So we're looking at that kind of a program here as well, which we think would be really beneficial to shifting those LPNs to an RN level once they've completed that program. The other thing we are doing is we've worked with Norwich, which we're very grateful for their partnership and we're looking at our associate degree RNs being moved to the BSN program. And we've worked with them so that they can keep their tuition costs to mirror what we're currently offering for tuition reimbursement on our organization, which is phenomenal for people to give them that opportunity to really continue their professional growth. At the same time, we hope retaining their employment here at CVMC and not looking elsewhere for those opportunities. So we're very grateful for those partnerships with our community colleges and universities. Thank you, thanks for that update. Also in the area of telehealth, I wonder if you could speak a little bit more to what you saw in telehealth, how that went, lessons learned, same sort of drill. Sure, so to Dr. Lefler's point, we sort of jumpstarted our telehealth journey here in very short order. There's nothing like a burning platform to get people to take risks. So I will have to say that our providers really did embrace it. Something that wasn't mentioned earlier that I think others experienced as well is what telehealth does is also reduces your no-show rate, which is not uncommon in rural parts of our state. So when patients can't have our transportation challenged, sometimes they just don't show up for their appointments. That's much more difficult to do when we're using telemedicine. So that was something that came out loud and clear from our providers of the just drop in the no-show rate for those routine appointments. The other thing that we had is we did survey our patients that experienced telemedicine visits and their response to telemedicine was really, really strong. We used Prescaini for that assessment and we did share that feedback with our providers who were really pleased to hear how well received the telemedicine visits were for our team. At one point, we were up to, similar to Dr. Lefler's experience, up to about 70% telemedicine visits from the primary care. We have dropped since then, but we have set standards for both primary care and specialty care for the level of telemedicine visits we want to continue. And of course, we do just offer telephone visits as well, which we did prior to, but again, it wasn't really until COVID and people really were thankfully socially distancing and staying home, staying safe. They were taking that to heart and so we really appreciated their being able to still access the healthcare system and not delay their care and treatment by using that service. So I would say overall very well received by our providers and also by our patients. Great, thank you. And do you have any lessons learned or things that you felt like were helpful in terms of the positive receptivity from your providers and patients? I think one of the lessons learned here was really on the scheduling side of scheduling telemedicine visits in a grouping. So instead of trying to mix telemedicine visits in with routine, in-person visits, it works best for our providers to have blocks of time when they just to telemedicine. And that was convenient for the providers but also helped us from a scheduling streamlining perspective. Great, thank you. You're welcome. And then Justin follow up on on some of the volume related questions. Where would you say you are as a percentage of normal in terms of your current volume? We're almost completely back to our pre-COVID levels of volume. And in our primary care, we're a little over pre-COVID because we're trying to catch up a bit even though we use telemedicine well, some of the in-person visits, the volumes have gone up a little bit. But as far as our operating room revenues, our PT visits, that kind of thing, we're pretty much back to our pre-COVID baseline. So we did not have any delay in that at all. When we opened up our pipelines again in May, patients came back, which we were kind of surprised about initially, but I think just all the communication we did during COVID to the community, I think helped people to realize all the safety measures that we had in place so that they felt safe. And we're certainly welcome to come back into the acute care space as well as our practices. And on clinic sites. Great. And then my last question is the sequestration elimination impacts on the budget for 2020 and whether that will be much of an impact and how are you factor that in? Yeah, so Robin, this is Todd Keating. We actually didn't put it into the budget this year. And the reason being is it's here or it's not here. And when something's 50-50, I don't necessarily plan for it. So we left it out. So if in fact it works, then we got a benefit. Great. And it's heaven as they say. Yes. And do you have any idea about what that is? The benefit? Yeah, it would be somewhere around a little bit over 100,000. It's not huge dollars, but it's good enough. Thank you. That's all I have for CVMC. Kevin, do you want me to hold my network question until the end after we finish Porter or how do you want to handle that? So I would appreciate if you figure out a way to ask the network questions by asking them through the affiliate. By statute, we have to have hospital budget hearings for each of the hospitals. And so it'd be better if you could phrase your question so they're asking it through the affiliate. I'm on the central Vermont board, Robin, as I am on most boards. So you can just ask me the question. All right, I'm just gonna ask Steve. Yeah, well, it's slide 20. You'll be shocked to know it's slide 20 that I'd like to come back to, which is the comparison between the hospital and commercial payer growth rates. And I very much appreciate that the quantification this year took a much more nuanced approach than last year. So I very much appreciate that. And as Mark Stanislav stated, it is a complicated comparison and there are a lot of factors which make it a challenge. So let me just talk about a couple of those factors. The first is the number of lives. So there's only around 77,000 Vermonters who are insured through the qualified health plans. As you stated earlier, your whole network, including New York touches on a million lives, that's obviously both New York and Vermont. But of course, not all of the 77,000 lives go to the UVM affiliate. So that in and of itself, to me kind of begs the question whether this comparison is really worth doing given the discrepancy in the populations. Second, I would just note that the blended medical and pharmacy trend is not comparable to the Green Mountain Care Board regulated entities. The pharmaceutical components that are included in the hospital budgets are included in the medical trend, not in the pharmacy trend. And pharmacy trend has been one of the largest drivers in the qualified health plan rates in the past. So that's another compounding factor. And then of course, there's always the health of the population issue in terms of QHP versus whatever your network's health of your population is, it's hard to know how those compare. But over the lunch break, I did take a moment to pull up our QHP actuarial memorandums and decisions from the last three years and calculate the Vermont Green Mountain Care Board regulated medical unit cost trend and average that out to try and get to a little more apples to apples. In the L&E's report, they do include a medical unit cost trend that is equivalent to the Green Mountain Care Board regulated entities, which is basically what we regulate through the hospital budget process. And so for Blue Cross Blue Shield, the three year average for that number plus, I did add in any adjustments that we made in the decision around hospital budget projections was for Blue Cross, 3.4% three year average for 1920 and 21 and for MVP was 3.7%. And so I think, again, it's very difficult to compare these numbers because they're completely different people in terms of the number and potentially the average risk. But I do think that and I'm sympathetic to wanting to compare it because I myself wanna compare it but where I've kind of come to in delving into these two processes is that I'm not sure the utility of comparing the cost trend for 77,000 people compared to a much bigger population, most of which is self-insured. So it's not really a question. I just wanted to kind of tell, kind of address this issue head on because it is an issue that we've been having a conversation about over a number of years. So you're welcome to respond or not. And your critique of the analysis is well-founded and taken. We're striving to maybe do the impossible as you are. A couple of components of that are to try and bring these regulatory processes of commercial rates and the hospital budgeting process more in sync in time and in measure. And as you point out, it's incredibly difficult to do that. And the other thing that I wrestle with almost on a daily basis is to try and explain the incongruity between what the premiums are doing that the folks that pay those are seeing, mostly employers, a lot of them, folks have subsidies and other things and what the increases are, the commercial rate increases that we on the hospital side are seeing. And that's a problem that we all share. We've had this conversation virtually every year because those two numbers are so divergent and everybody categorizes healthcare costs. You may hear that I'm not speaking from a bowling alley. We've got a big thunderstorm going right now. But we all struggle with trying to talk to the public about that. Mark, if you wanna make a comment, but if you really wanna get into it, I would suggest that you sit down with Member Lunge or others who wanna hear you go into depth on this. Actually, I think the only thing that I would say, John, you know, whether we would welcome the conversation, we do think it's a little bit broader than that category. And while it doesn't explicitly say in this L&E report, there was an L&E report a couple of years ago in the pharmaceutical that said a big driver of that was chemotherapy and infusion drugs. And, you know, we would argue that the setting that the majority of those are provided under, okay, is a hospital setting, but it is very complicated.  You know, because the other thing that is difficult is there's a three-year lag. So like, I don't know how you apply the 1.9% trend factor that came through in FY21 for 2019, back to 2019, because I'm assumed some of that has to do with rates. Okay, and it just seems odd that when you look at the trend in pharmaceuticals compared to other medical inflation where regards to how you look at it is two or three-fold and we're also seeing that same thing internally, I think all of the hospitals. So I think it warrants a conversation and I do think it needs to be deconstructed or, you know, to the extent that we can.  Like there are years, like on a three-year cycle, certain hospitals might go through a union negotiation and how that ends up compared to budget. You know, we never go back and change what the rate inflation is related to that. But, you know, I think this is one area where, you know, I would welcome spending time with a couple of board members, you know, to see if we can, you know, deconstruct it a little bit better and say, you know, here's where we have agreement and here's where we have differences.  And I appreciate that and I also welcome that. I'm happy to sit down anytime. What we had heard from our actuaries is that about every 1% in a hospital, the Vermont hospital commercial rate increase system-wide is the equivalent of about a 0.5% increase in premiums. Now, that may vary a little bit year to year, but, and that's in part because for each of the carriers for Blue Cross, only about half of their medical cost is regulated entities, meaning hospitals are hospital-related. The rest is out-of-state and unregulated healthcare providers. MVP is even lower, it's about 40%. So there is a lot more in that premium and even just in that medical trend than what we're talking about today. But I would welcome that. And we would also, as you may know, we have parts one and two of a regulatory white paper on our website that's open for comment. We very much welcome comments from anyone and everyone, but also happy to sit down, so thank you. Is that all you have for questions, Robin? Yes. Okay, moving to member Pelham, Tom. Thank you. I have a bowling alley showing up at my door too. It's Sonny and Rutland. Well, or maybe it's a psychosomatic and Mr. Brum should put it in my mind, but I'm hearing noise out there. So my questions, and by the way, I very much appreciate the conversation that Jess and Robin and Mark are having because it is a place where you can get, it's hard to tie down. So I mean, three of us can't be together at the same time, but I hope that conversation does unfold. I only have a few things. I wanna go again to the provider tax here for Central Vermont. They are budgeting against their 2020 projection for NPR and FTP at a 7.2% rate on the provider. And their rates in the prior year were in the 5.7% plus or minus range. So it's just kind of a, just a check on that to make sure that, because the difference is a couple of million dollars between that 7.2% rate and a 6% rate. This is probably my confusion, but when I was looking at your rate table, it has for a change in charge at 6%, raising $183,000 in Medicare funds, but then the rate for a 1% change was $895,000. So that confused me a little bit. We don't have to figure it out now, but it's just a note. I had a question as to whether or not Woodridge is completely separate from the hospital, or is there any interrelationships like what we see at Porter? Woodridge is under the same 10 as the hospital proper and the practice division. So we're all one. So Woodridge's dollars, their budget is part of our submission. Okay, thank you for that. I'd also like to kind of know a little bit more about the non-operating income increase from which is a two and a half million dollars and a 61% increase because it says it's interest. And so we're looking forward and saying that interest will increase by two and a half million dollars. And I'm just wondering is there, what is the risk around that number? Yeah, so it's a great question. So I think that the descriptor should be its investment income. So it will be the income from the portfolio that we have for the organization. So the label of interest only is not necessarily appropriate. It should be more inclusive to read investment income. Okay, but obviously relative to prior years, you're looking for a significant increase in that. Yeah, there was a little bit of lag still. It has come back in recent months. Remember, we put this together a few months ago and everything and stuff. So we might have recovered it already based on where the stock markets are at all time highs. So we'll have to wait and see how next year comes out per the election. Okay, thank you. That's all I had. Thank you, Tom. Todd, we heard testimony from other hospitals last week that talked about they're seeing interest from providers that are actually calling them to see if there are openings. And so they had booked last for travelers and locums. We heard Anna's comments just a few minutes ago and talking about the great efforts that Central Vermont Medical Center has made. So I'm just curious why you brought that number up for this year's budget. So what it happens, a great question, Chair Mullen. So what had happened historically, we were actually on the other side of that in that we would budget to FTEs and then we'd actually incurred 12. So this year, not knowing what the success of the new programs were going to be, we decided to be somewhat conservative. And instead of budgeting the two, we budgeted the 12. And now as you've heard Anna say, we're somewhere around eight. We're hoping that to her point, that the trending is right and it continues to go down so we get to zero, but we're kind of in between still. And so we're hoping with a $98,000 delta between the two, we're crossing our fingers that the LNA and LPN programs continue to get traction and take them out because the reduction that she talks about was literally cutting it in half in a very short period of time based on the graduates from these different programs. Okay, thank you. Walk us through the thinking behind all the medical providers all being part of a UVM medical practice. And does that mean that there's higher reimbursement for those doctors because of the treatment that way? Or how does the money flow between central Vermont and paying for these doctors who are practicing in central Vermont and this new UVM doctor entity? Rick Vincent is the CFO of the medical group as well. And so Rick, maybe you can talk a little bit about the reimbursements, taking a step back the rationale for one medical group. The principal driver there is quality of services and access and the ability to recruit and retain in a much larger group. So we can get into the dollars and the reimbursements, but the basis for doing it really is around the delivery of healthcare services, correct? Yeah, so it doesn't, Chair Mullin, it doesn't change the reimbursements. So the reimbursements are still always tied to the tax ID numbers of the hospitals. So the way that the funds flows work is the medical group has its own tax ID number, but at the end of every month, essentially it gets zeroed out. So it has a payroll that employs all of the physicians and that cost gets allocated out to each of the hospitals. So there's some physicians, obviously, they get allocated out to the UVM medical center, some to CVMC. So they essentially pay for the physician capacity that they're getting provided at Central Vermont. So there's no billing that happens out of that UVM medical group tax. Are there advantages, say for example that Anna needs 1.5 urologists in Central Vermont, can you then share that half of urologist so that it's a full-time urologist, but half of it might be at UVM and the other half at Central Vermont? Absolutely, that's one of the benefits of having all one medical group, particularly when you get into some of the departments that have truly become network departments like pathology, radiology, anesthesia, ED, those types of areas where if you don't need a full-time person, now you're part of a group where maybe you only need one day of coverage or two days of coverage, that's obviously much easier done in this physician organization. So with this new entity and you're calculating, I assume they're all getting paid out of the new entity. So how is the calculation done that determines how much is transferred from Central Vermont Medical Center to the doc group to pay for the services provided? It's based on whatever amount of effort that they're putting at that particular hospital. So if somebody's 100% at the medical center, the medical center is getting 100% of that cost. If it's split 80, 20, 20% at the Central Vermont, they're gonna get 20% of that total cost of the physician. So are you doing a cost accounting by provider and bumping in all the costs associated with them, salary, benefits, et cetera, and then allocating that out? Correct, yep. Okay, great. So likewise in that same vein, Todd, maybe you could walk me through what the allocation is for the administration of the network itself between the entity. And if that methodology is identical across all five hospitals or all that works. Yeah, it's a great question. So the allocation methodologies vary depending upon the type of service that it is, but they are consistent for all the different entities and such. So for some, we have some of our services that are split based on what the revenue percentages are across the network and stuff. So if the medical center is 60%, CVMC is 20%. A costly fine, for instance, would be split on that 60, 20. And then the other portion would go out to the other entities. There are some, you know, like with Epic for instance and stuff where it's gonna be done on a use rate. So, you know, as an entity- I'm sorry. I'm sorry. It's breaking up a little bit. And I'm not sure why there's some background noise, but you said done on a use rate. Go ahead. Yeah, done on a use rate. So as, you know, organizations use Epic for instance, that the allocation of the Epic operating costs will be allocated out based on that use rate and what have you. And then there are some that are just fixed, you know, agreements and everything where an allocate will be done very consistently from year to year show no fluctuation. So it really depends on what the services and what the agreements are do the allocations. So again, I'll just ask if you're not speaking to me yourself, we can hear some background noise. Maybe Todd, you're getting huge droplets of water pouring on your roof. I don't know, but. The sun's coming out now. Okay, so we were hearing something, but hopefully everybody will mute and we can move on from there. My next question is, can you walk us through what CVMC has asked for in terms of FEMA dollars and CRF dollars? Yep. So as Rick mentioned earlier stuff for the CRF dollars, the lion's share of the ask is about $3.8 million to be offset against the one care adjustments for the Medicare AIP BP funds. The rest is gonna be about $2 million that'll be split between FEMA and the CRF funds. The CRF funds, you know, the majority of it will be going to FEMA. And then as Rick mentioned, 25% of it was applied to the AHS. So it's about, if you round AHS or excuse me, CRF, it's a little bit over $4 million where you have about a million and a half to $2 million going through FEMA. Okay, thank you. And I think that's all I had for questions. So at this point, I'm going to turn it over to the healthcare advocate, Mike Fisher. Thank you, Mr. Chair. I have no questions for CVMC. Thank you. Okay, at this point, we're gonna open it up for public comment on the budget for Central Vermont Medical Center. Is there any public comment? Is there any public comment for Central Vermont Medical Center? Hearing none, we're gonna move on to Porter. And Dr. Holmes will start the questioning for the board and I'm getting a chuckle because we've seen to have somehow lined this up where Tom, who was from Arlington originally got Southwestern Vermont and Robin who was originally from Brattleboro got Brattleboro and now Jess, you have your hometown hospital. So go ahead. Okay, well, thank you. So let me start. Maybe this is a question for Jen probably about some of the NPR assumptions for 2021. I'm looking at, I don't know if you have this in front of you, I'll show you, but this is a table that is piled for us by the board, basically has, it's part of your submission, shows 2019 actual NPR and fixed payments by payer, then it shows the 2020 budget, 2020 projection and 2021 budget. And as I'm looking at this Medicare from 2019 actual to 2021 budget pretty closely aligned, Medicaid 2019 actual to 2021 budget pretty closely aligned, then there seems to be a big jump between 2019 actual for commercial, which was about 42.6 million, bumps up to 2021 budget up to 47 million. So Jen, I'm just wondering if you could, since the other payers seem to be kind of flat with the NPR assumptions between 2019 actual and 2021 budget, you could just give a little bit more context on what you think is happening with commercial to generate that bigger jump. I'd have to look at that a little bit more in depth, board and homes, but I believe a portion of that is related to there was a change that we've been accumulating over time in terms of some shifts in our commercial payments from our main commercial payer to some of our other commercial payers, specifically with one employer in town and we're starting to fill the compounding effect of that and that change in reimbursement because there are differences between the two and the way our contracts are formulated. And I think that's a reasonable portion of that change from one year to the other, because with one of our commercial payers, we have a fixed level of reimbursement for inpatient and the other payer, we do not. Okay, sounds good. If it's not what that is, and you want to get back to me, that's great. Okay. I'll double check on that, but I'm pretty sure that's what's related there. Okay. And I guess it's just another question, being the hometown hospital, I do read the Addison independent. And the Addison independent reported basically that there was, the budget proposed a 0% increase for both inpatient and outpatient fees, right? Which I understand, of course, is a 0% increase to charge, but in effect, we know that there's a commercial rate increase, effective commercial rate increase of 5.75. So I'm just wondering, is there a better way to report in your budget submissions, the actual effective commercial rate so that people in our community and others can really understand how the proposed budget is really going to affect their checkbooks because there does seem to be, people don't always quite understand what that difference is. And I would say that across the hospitals, the UVM Health Network is the only hospital that actually submits two different, a charge and an effective commercial rate. Every other hospital just basically submits an effective commercial rate, it seems, as far as I can understand. So it's just, when I've read it in the paper, I was thinking, well, that's not exactly right. There is going to be a bump up to commercial rate payers in the community. So can you think, is there something we could be doing to better help people understand what the impact is going to be or how it's reported or submitted? Yeah, you know what's funny? I was trying to explain this to the interviewer. When we were going through the interview process and because of its complexity, we kind of just said, you know, we'll table that. But I think there's an opportunity to your point, Jessica, that we could sit down and have a conversation about that and break that down a little further. It's not an easy thing to differentiate and it's really based on how we're reimbursed. An increase in price for us does not equate to an increase in reimbursement. You've heard me definitely say that and that's really because of the way our contracts are structured. And I think that we could, you know, try to define that a little bit better but it is complex. And when we were trying to go down this road, I did lose him a little bit in that, in all fairness. No, I'm not surprised. So just thinking, how do we communicate this better? Jessica, if I might just chip in, I think that's one of the reasons why one of our core strategies here is to engage our community in multiple ways because it's in our best interest to have an informed community. And although it's a complex subject and has been forever, the more that they know the better the way they can advocate. And quite honestly, the best we can learn from them. And so I guess my last question is the same question I posed to Anna about the affiliation, right? Obviously there's lots of conversation around about consolidation and its impact on Vermont or so. I have some sense of what it's like from living in this community, but I'm wondering if you can talk a little bit about the benefits or the costs, consequences, impact, however you want to describe it of the choice to affiliate and how you think the community views that affiliation. Just to add more context to the conversations that are happening around consolidation. Right. So I'd be glad to take that one out of the gate and then Jen, if she has information to add. Having been, again, as was mentioned earlier around for quite a while and served in a variety of health systems ranging from ones of the scale of ours to common spirit health, which is now the nation's largest faith based health system and a couple in between. And having had the opportunity to participate in those companies as they evolved toward an operating company model, as Dr. Brumsted mentioned, what I appreciate is a great time to be at the University of Vermont Health Network. First off, be at the formative stages of this health network. And what I would tell you is different about my experience having had prior experiences in this work is how attached our leadership is to and respectful of everyone's inputs into its design and how we are stronger for our community. Dr. Brumsted not only is on our board by name, he comes to the meetings and is engaged in what we're doing. So I mean, it's exceptionally engaging and community based, which I think is the Vermont way as I'm learning as a Midwest flatlander, but is definitely respectful and powerful and will make us a better system. I will give you a very practical example, just over the weekend, as was mentioned by Dr. Brumsted in his opening comments, we had unfortunately our first experience with a COVID positive resident at Helen Porter. And immediately I myself, our patient services director, our Helen Porter administrator, the medical director, infection control, everyone had access to their network peers for consultation and to learn from the experiences that had gone on in Burlington as we determine the disposition of this resident, et cetera. That is the bench strength that is sure it's available by networking if you're not affiliated, but it's built, it's baked into who we are, right? So that is huge. And then there's obviously the access to technical resources that we couldn't obtain because we don't have the depth that do it in databases and planning and those different things, economy of scales as been mentioned. The medical group which has been discussed a variety of times and it was a great question by I think it was Chair Mullen about the access to specialty care and a community of our size. We can't justify a specialty X, right? But we can support local care by having a partial person that will take the left side of the person. Anyway, so I mean, we have access to people that we wouldn't have access to otherwise, right? As far as our community, I'm a relative newcomer to the community, but people that I've encountered are appreciating and understanding that the access to, well, in future times, the access to capital in our organization, the access to the professional expertise, the halo effect of attachment to the academic medical center is all creative to our organization's sustainability. I'm not hearing it in that exact language, but I'm hearing that message. So I don't know if you have anything else to add. No, I don't want to do a great job. Great, thank you. That's all my questions. Thank you, Jess. Next, we're going to Board Member Lunge, Robin. Thank you. So I was interested in hearing a little bit more about the temporary staff that you mentioned in your narrative and your budget submission that you've needed for screening and sanitizing. Can you talk a little bit more about that? How many people is it, that kind of stuff? Sure, so we have actually only one temporary person right now that we had just brought into the organization and that was post-budget. In our budget, we did not incorporate any of this temporary labor for COVID. What we were able to do was basically, for lack of a better term, shuffle the deck chairs, so to speak, where we had people coming from the practices and other support staff being able to fill in as those screeners and some of the environmental services staff. But what we're starting to see now is as we're coming back online, there may be a further need to go down the road of adding a little bit more to that temporary staff for our respiratory clinic that we have on campus that for drive-through testing that we still have here on campus and then maybe one other. So I'd say in totality maybe three to four temporary FTEs that we may have to look into in the near future because of the screening and just other processes throughout the organization we're having to adjust to. Great, thank you. And is that reflective of all of your travelers and other contract labor? Or I know I asked it in specific to the COVID, but if you could put that in the context of the full, that would be helpful. Sure, so unfortunately this year we have experienced a higher rate of traveler FTEs than we had originally anticipated. Although I will say we've been able to by the time October comes around we would probably be able to mitigate a good portion of those. Right now we have about 13 travelers in-house. And really it's because some of the graduates that we were able to attract as all of the COVID influx had occurred it was really allowed those graduates to kind of be able to get their certification sooner and things of that nature. So we actually were able to recruit quite a few of those positions and right now they're orienting so you have that overlap and we anticipate that that may go away or at least reduce I should say, not go away but reduce in October. However, I will say that we did increase our temporary labor assumptions in our budget. We went from about three FTEs that we normally incorporate into the budget and we added about 3.4. So we have about 6.25 FTEs of nurse travelers. That's really where we're seeing the need is in the nursing traveler labor. Cool. And are those in specialized departments or more general or? For the most part it's our part to be honest with you and our ED is where we see it the most. We've had to apply a little bit more recently on the med search floor but we haven't seen that as much in the past history. It's really the OR and our emergency department that we need to rely on those. Great. Well, I would also suggest you talk to Brattleboro because they've come up with a very innovative approach to try and reduce their OR nurse traveler FTEs and they're expecting to get to zero from quite a high number at one point. So just a little sharing of best practices. Sure. Could you also speak a little bit more on telehealth? I know you mentioned that you had at one point over a thousand visits and just the same questions that I've asked the other two folks. Yes, it went from zero to 80 really quick. Yeah. So the numbers grew quite well. Our providers were very good adopters. We have a champion, Dr. Natasha Withers who I refer to in another context within our practice who is really kind of a champion for making this work well for us with both providers and with our patients. There were instances where she was scheduling meetings with patients who were technologically challenged to coach them a couple of days in advance of their clinic visit on telemedicine so they could be successful. So I mean, there was that kind of work. We said, so we should do trial runs. And we actually put the word out for Helen Porter. Well, actually it's for the organization but the plan was to get iPads so that we could get connectivity for residents at Helen Porter with the outside. We got 14 iPads overnight in that request that went out to the community. And I think I did mention this earlier but we will, you know, typically in the past the payer side of the equation has looked at telemedicine as a means of reducing cost. Providers have looked at it as means of enhancing access. I think what you'll see long-term is we desire to keep a high level of telemedicine involvement because as it was mentioned, it reduces, everything Anna said, it reduces no shows. The patients love it once they get acclimated to it as do the providers. And we will need to work to ensure that we maintain some level of payment equity or parity so that we can have that, that's not really even an innovation but that new practice persists. Thank you. I was also curious, so you may, it may be embedded in your materials and I missed it but could you talk a little bit about your Medicare assumptions and sequestration? So our Medicare assumptions took the traditional trend of our cost-based reimbursement that we do every year by running it through the model. As it pertains to our sequestration, we did not incorporate an assumption for the 2% sequestration in our FY21 budget but I will tell you that it quaked to about $27,000 for the three months that we would be experiencing into the next fiscal year. Very small. Thank you. But we'll take it. Yeah, of course, sure. And then I'm almost finished with my question. So in terms of where you are in terms of your volumes currently, do you think you're about back to normal or are you still lagging? I think we're at 96%, everything's come back quite well. Interestingly enough, our express care which is our convenience care type service has been the slowest to return. And so we're working on understanding that. Interesting. Thank you. I could add a little bit to Robin on, we did see quite an increase though in July in our lab services by about 20% actually. So we are anticipating that we will still end our year cautiously optimistic right now that we will end our year back at 100% in fact on target for our margin. Great. And then could you also give us a little bit of an update in terms of your, I don't recall when you were gonna start on your Epic implementation. But now I'm getting the thunderstorm. We're on the same pace with CVMC. So we're in the midst of our wave two preparation going live in March. We went live on the ambulatory side in all last year and all is going well with that work leading to the March deployment. Okay, great. Thank you. That's all I have. Thank you. Thank you Robin. Now a board member, Pelham, Tom. Thank you. Here we go. Tipped me a while to get the unmute. It's pouring out here now. Robin and I just live over the hill from each other and it's pouring. The Porter proposal was very easy, I thought. It was well put together and simple and all of my little boxes, most of them got checked, you know, 2.7% is less than 3.5. The provider taxes come right in at 6%. And so as I went through them all, I said, well, why couldn't they all be like this? But the only thing that kind of, not concerned me, but interested me was the relationship between your total and operating margins and the impact of the Porter nursing facility. And just wondering, you were projecting that the net of that on a consolidated basis would be 2.5% for the operating margin and 3.2% for the total margin. And I'm just wondering, is that a relationship looking in the rear view mirror that seems to be a settled relationship or is there a lot of volatility around that relationship? In terms of, we've experienced this year over a year, honestly, Tom, we consistently subsidized Helen Porter for their margin losses. And it's really to sustain this resource in our community and we feel it's vital for our community. But we do experience that year over here. Now we've gone through some significant cost cutting and as well as cost avoidance with Helen Porter and we've really tried to get that in line as much as we potentially can. But their rate of reimbursement is very different. Now it did improve this last year but their wage pressure on the LNA and LPN side, it's just really significant. And a lot of that is playing into their margin deficit. And Tom, I don't know if you can add to that at all. Well, yeah, and the thing I would add is the service that is marginable at Helen Porter is the short-term rehabilitation unit. And that service unfortunately has continued to be suppressed post our first wave of COVID because that's where any resident who is admitted to that facility is quarantined. And therefore it cuts into our ability to serve that rehab volume. So who knows when that's gonna break? So that's really a challenge there. Okay, so it sounds like there is some risk there that it was your presentation that on a consolidated basis, it was 2.5% and 3.2%. But it's just a relationship that's evolving over time, apparently. Yes, and to Tom's point, we are being cautious because there is additional risks. I mean, what we presented in that 2.5% and 3.2% margin is relatively the status quo for Helen Porter. But to Tom's point, we've had to drop our census on the post-acute unit by a significant amount. So we go from normally having an average of 21 on our post-acute unit down to 14. So that's certainly having an impact. And that's due to the fact that we need to go through the quarantining process to follow the guidelines that we need to for Helen Porter. So there is a risk in that as we go into FY 21 if we have to continue like this. Well, thank you both. Thank you, sir. Thank you, Tom. A member, Yusuf or Maureen? Yeah, just a couple of questions. Can you talk about the change in the ACO reserve and what the impact was year over year? So what did you have in 20? And then what are you putting in 21? I know you're not putting in anything in 21, but that would be a positive impact on your NPR. It is. So in FY 2020, we had assumed a million dollars in a risk reserve. And that was also incorporating rollover from the 2019 fiscal year as well. So when we presented our 2020 budget, we did only incorporate one million with that thought process that we would roll that forward on the balance sheet, which we did do. And then because of our favorable performance, so we've been able to recognize 1.1 million dollars of favorable performance in both 18 and 19 fiscal year, or excuse me, calendar year. And so with that being the case, keep into our word from a couple of years ago and recognizing success with the model, we did adopt that philosophy of reducing or eliminating the reserve. And so in FY 21, we did not incorporate a reserve and you are correct. It does have a favorable impact on our fuel of budget to budget on that dollar amount, that PP. Okay, and then what's left on your balance sheet from the reserves after you settled it all out and how much is your, what would you estimate your risk orders for 21 would be? So we would have about $2 million when we end the fiscal year in 2020 that we would roll forward in 21, which is about the amount of our maximum risk for 21. Okay, which is what we kind of thought might happen, right? You'd end up with reserve and then you just tweak that reserve. Right, exactly. And of course, you know, I love it going to NPR. I do. This way you stayed still within your cap and you have this change. So. She's been waiting for that question. Yeah. And then another question on, in your narrative, you had a 2.1 million of increased cost to living expense market adjustments to address wage compression, position salary adjustments and non-labor inflation, which is a pretty high number on top of your, about 50 plus million in wages and salaries. So can you talk a little bit to that, you know, especially in the context of is what's going on in the rest of Vermont where most people are not necessarily seeing wage increases or, you know, have been unemployed or taking wage cuts. So you just wanna talk about the timing of that, the cost of that and give us some more color. Sure. We did incorporate 2.5% and historically we have struggled with our attention and recruitment for a quarter. And so in order to ensure that we at least try to mitigate that issue going forward, we certainly wanted to include a cost of living adjustment, which is 2.5% for the majority of our workforce. And that equates to, if I remember correctly, about a million dollars of that figure for our general workforce. And then the providers also receive a market adjustment and that's at about 3% for the providers. And then of course, we did incorporate an increase for benefits on top of that, so it's about 4%. So the majority of that is made up of those three areas. And we do incorporate one other thing and that is to address compression of our existing staff. So we do incorporate a market adjustment for some of our existing staff that we need to adjust to based on our results that we see from our market analysis consultant. Okay, and then this question may flow through to some of the network too, but were you impacted by some of the cost reductions on staff, the 10% for over certain levels and the variable comp? And so I guess first question would be for Porter, were you impacted by that? And if so, then what happened to that as you move forward into 2021, does it right set back to where it was and then you add two and a half or what? Yeah, the approach that was uniform across our network. And I can take that one and one of the CFOs or Todd, correct me if I don't have this right. The beginning of the 21 fiscal year were restoring the 403B employer contributions across the board, directors who had a base salary cut. Their salary is being reinstated and the physician comp plan is actually morphing a bit and Rick, you might comment on this, but to reduce a variable component but we actually are doing a market increase for the physicians that hits on the first of the year. The vice presidents and above will have their salaries and their salaries, and benefits restored the first of January if we're close to tracking on budget. And if we're tracking on budget through April, anybody VP and above that is below median compensation based on our benchmarking overseen by the board compensation committee will get a 2% essentially COLA, but only if their starting point is below the median, which is our compensation philosophy, which is to have our senior executives be at median. So that's, I believe the way that we've paced that out. I got that right, correct? So yeah, all right. Yep. Okay. And I had one other question that I think may actually just be on UVM, but on the pension plan adjustment that you did and you talked about recognizing all the actuarial losses in one year instead of over the 30 year horizon, I think that was going into down kind of below the line, but between your property margin and your total margin, can you tell me what the impact of that was for the pension? Yeah, so that, since we are on track to terminate the pension plan at the medical center, and I want to be careful with the word terminate, it doesn't mean the pension's going away. It means the liability is essentially being sold to an insurance company for anybody that doesn't want to take lump sum payments. But once that happens, when the plan goes away, you essentially have to, you've got to clear out the other pension liability from your book. So with that pension accounting, all this is below the line. So nothing in operating income, it's all in terms of the total margin. And I try to remember the exact amount, but I think it was somewhere, I'll have to get back to you Maury, but I think it was somewhere around $18 million in what we budgeted as kind of the final closeout, which we anticipate to be sometime in July of next year. But it's important to note that, because you look at the operating margin and the total margin, because at the end of the day, it's where are you coming out in total margin and cash and things like that. And so this is a one-time adjustment that is impacting your total margins this year. It's good to just go with it. Okay, thank you. We did budget for it, knowing that that was gonna happen next year. Yeah, okay, good. Kevin, before you go to public comment, can I ask a quick question? Sure. Okay. I'm gonna ask a few of myself. Go ahead. Go ahead. Go first. No, go ahead. No, no, no. Go ahead. You're the share. I guess I'll follow up to Maureen's question about the COLA adjustments. So 2.5 for Porter, maybe 2% for EVM. I'm just wondering, I think I'm wondering what you're using for your COLA adjustment. Only reason I ask is because I happen to be just poking around looking the other day. And I think the CPIU, which is for New England, which is being used, I believe that's what's used for, for example, state employees and teachers, how they adjust their pension contribution or distributions, that's trending less than 1% for, for what's happening now. So I'm just wondering what you're using for a cost of living adjustment. So you can either answer that later or quickly now, if you have a quick benchmark that you're using, where you got 2.5. Well, each CFO can just say what you put in your budget. Yeah, so for the UVM Medical Center, there's two groups of employees where there's, it's driven by contract. So we have our tech union and our nursing union that that is, there's nothing, it's not a COLA increase, it's just driven by the contract. So the nurses contract has a 2% market, 2% step in it that's been built into the 21 budget. The tech union has a 2% market, 1% step that we've built into the budget. And then the rest of the physicians are around that 2% range for, you know, market range movements and compression and all those other categories are all kind of that kind of 2% range. Yeah, Jessica, for CVMC, what we do is we use a rate very similar to the Medical Center because if we start to lose traction with regard to equity, we start losing employees to the Medical Center.  So that's because it's only a 40 minute drive from, you know, one to the other. So. And we use a compensation consultant and the amount between our steps for our general population of staff is 2.5%, which is what we're talking about for us. Great, thank you. Sorry, Kevin. Is that it? So I'll do a follow up on Jessica's question first. We've had at least one other hospital went to their union and the union voted not to take the 3% given everything that's happening in the world right now. Did you consider going to your union? Well, right now we are right in the middle of those negotiations with our union right at the present time. So those are ongoing conversations. Okay. Go ahead. Rick. I was going to add for the Medical Center that we did a tremendous amount of work with the union around furloughs and around the ability to flex people to different floors, which was, I won't say outside the contract, but was part of hard work we did. And we made that conscious decision not to open up salary or benefits because they were actually great partners in getting us through the first wave of COVID. Absolutely. Yeah, the other thing I would add is just, I mean, those rates that, what we have to be careful of as well is, if we're not keeping pace with the market, that's just going to drive the number of travelers up that we need. So I think there was a concern that if we don't implement those increases, we could fall even further on. Okay. I'm just going to follow up on Tom's question because I had the same line of thought and I look at the loss on the nursing home side and from personal experience, I know that you have some really great private facilities there that other parts of the state, they have a policy where if someone can go in and pay for three or four years, then after that, they're willing to take the Medicaid. At least one in Middlebury does not have that.  So I understand the need for Helen Porter in the community, but at the same time, when you see a hospital like North Country divesting of their nursing home in Derby so that they don't have any losses, it's just very frustrating. And I hadn't understood the rehab side until you talked about that. But I will say on the remaining reimbursement, I think it's more appropriate that you should be fighting with Dale to get that reimbursement, then trying to put it on the backs of the commercial ratepayers in the state of Vermont because other hospitals are not doing it the same way. And so it gives one community a little bit of an advantage over another. That's all, it's just an equity thing. No question, just my ramblings about that. Could you walk us through what you're putting in for, for FEMA and CRF funds? So for the CRF, we're doing the same as my counterparts for requesting reimbursement for the Medicare ACO reconciliation, which is about $778,000 that we're requesting. As for FEMA, we did apply, however, we are resending our application due to the fact that we were able to cover our expenses through other grant funding through the state, such as ASPR and the Bahassee grant, things of that nature. So we were actually able to cover our other expenses. Okay. And Jen, one last question. It hasn't been easy for critical access hospitals because of the cost reporting for their participation in one. And you seem to be a bright star out there that's figured it out. Do you have any words of wisdom for your fellow CFOs around the state? Yeah, I think one of the things that has helped us is just really one resiliency, I guess, but then two is the fact that we've really dug in and worked and partnered with not only yourselves, this is the amount of care work, but also with CMMI to really make some changes and with OneCare as well, and really spent a lot of time walking through what we need. And I think we've worked through a lot of those complexities so far. You know, our, what we call our PSNR, which is our cost report Bible so to speak that we use when we go to do our filing. We've been able to work with CMMI and that's now been fixed as of a couple of months ago. And that was a big deal for any of the participants. And I think that's really just those hurdles that we've been able to overcome. I think that's really a testament to where we are today. And I think going forward, it would be beneficial for some to come into it now that we've overcome a lot of those hurdles. I wish we could clone you, Jen. Chair Mullen. Thank you, that's really fine. Chair Mullen, no, I have to live with her. So if I may, if I may start, I'd like to comment on the Helen Porter subject because, you know, having been in this sort of a care continuum a few different times in my career, I have confidence that we can narrow that subsidy level that's currently being required. We're being artificially constrained by that right now because of the COVID scenario. But as a component of how we manage care across the care continuum, there's tremendous upside value. We just have to design our care that way so that we can lower, for example, lower the amount of time, perhaps for some of our diagnoses that a patient spends in our hospital and can be discharged in that post-acute unit. That's what we have to lever a lot more with a lot more discipline and design in the future. And I think that will help us close that gap and provide better care for our patients and residents. Thank you, Tom. Yes, sir. With that, I'm going to turn it over to the healthcare advocate, Mike Fisher. Thanks. I have just one question. Let me just first introduce myself, Thomas. I'm up here in Lincoln and it seems like... Was fishing there this weekend? So barely, but still in Addison County. And it seems like whenever anyone's about to ask questions, what was it, the bowling alley seems to come. So that's happening. I just have one question and it's a historic question, one that I've asked for many, many years in various roles. And you may not have a perspective on it, but there is a long-term challenge in finding enough medication-assisted treatment providers in our community. And I would, if you have any insights or any update on that dynamic in Middlebury, I'd appreciate it. You don't, I don't know the subject that well for the Middlebury care environment. I don't know if Dr. Brumsted or Dr. Leffler do. All I do know from past experience where the provider's willing to accept patients where there's a challenge to maintain those providers because their practice got subsumed by it. So I don't know if anyone else has any comment. I don't know the history here with it. Yeah, that's okay. I, it's just a question I've asked for many years and going back many presidents now. Steve, do you have some comments on that? I have a brief comment on that. So Mike, one of the things I think is going to make a great difference over the next couple of years is all of our trainees now. So every family medicine resident, every internal medicine resident gets training and gets the waiver. So the way you change people's practices, you train them in their residency, what their future's going to look like. And once we, since we've made that change and they're all carrying a panel of patients, they know what to expect. So I just think we have to basically be graduating these residents into our communities and that's going to help more than anything else that we could do.  At least that's my perception. So I appreciate that answer and something to continue to focus on. And also I would just say that, you know, Dr. Peterson here, who's the chair of our family medicine or yeah, family medicine, all of those providers now are getting the waiver and are expected to have a panel of patients. So, I mean, Tom, if we can help with Addison, of course you'd be happy to. I think I do believe the FQHC practice in Bristol has at least one provider, right? So. Thank you. That's it. Thank you, Mike. At this point, we'll open it up for public comment on Porter. Is there any public comment? Well, Tom and Jen, I think you're the benefit of being last because I think you've worn down the comments. In Tom, you did excellent in your first year of hospital budget. So good job. Oh, thank you. It's very interesting. So with board members, is there any type of emotion to adjourn? So moved. So moved. Second. It's been moved and seconded to adjourn. All those in favor signify by saying aye. Aye. Aye. Any opposed? Thank you, everyone, from the UVM Health Network. It was a very informative day and we really learned a lot. So thank you all. Thank you. Have a great day. Have a good evening.